Prior to beginning work on this discussion, please read Chapters 3, 4, and 17 in DSM-5 Made Easy: The Clinician’s Guide to Diagnosis; Case 20 from Case Studies in Abnormal Psychology; and Chapter 1 in

CHAPTER 3

Mood Disorders

DSM-5 notes that issues related to genetics and symptoms locate bipolar disorders as a sort of bridge between mood disorders and schizophrenia. That’s why DSM-5 separated the deeply intertwined chapters on bipolar and depressive disorders. However, to explain mood disorders as clearly and concisely as possible, I’ve reunited them.

Quick Guide to the Mood Disorders

DSM-5 uses three groups of criteria sets to diagnose mental problems related to mood: (1) mood episodes, (2) mood disorders, and (3) specifiers describing most recent episode and recurrent course. I’ll cover each of them in this Quick Guide. As usual, the link refers to the point where a more detailed discussion begins.

Mood Episodes

Simply expressed, a mood episode refers to any period of time when a patient feels abnormally happy or sad. Mood episodes are the building blocks from which many of the codable mood disorders are constructed. Most patients with mood disorders (though not the majority of mood disorder types) will have one or more of these three episodes: major depressive, manic, and hypomanic. Without additional information, none of these mood episodes is a codable diagnosis.

Major depressive episode. For at least 2 weeks, the patient feels depressed (or cannot enjoy life) and has problems with eating and sleeping, guilt feelings, low energy, trouble concentrating, and thoughts about death.

Manic episode. For at least 1 week, the patient feels elated (or sometimes only irritable) and may be grandiose, talkative, hyperactive, and distractible. Bad judgment leads to marked social or work impairment; often patients must be hospitalized.

Hypomanic episode. This is much like a manic episode, but it is briefer and less severe. Hospitalization is not required.

Mood Disorders

A mood disorder is a pattern of illness due to an abnormal mood. Nearly every patient who has a mood disorder experiences depression at some time, but some also have highs of mood. Many, but not all, mood disorders are diagnosed on the basis of a mood episode. Most patients with mood disorders will fit into one of the codable categories listed below.

DEPRESSIVE DISORDERS

Major depressive disorder. These patients have had no manic or hypomanic episodes, but have had one or more major depressive episodes. Major depressive disorder will be either recurrent or single episode.

Persistent depressive disorder (dysthymia). There are no high phases, and it lasts much longer than typical major depressive disorder. This type of depression is not usually severe enough to be called an episode of major depression (though chronic major depression is now included here).

Disruptive mood dysregulation disorder. A child’s mood is persistently negative between frequent, severe explosions of temper.

Premenstrual dysphoric disorder. A few days before her menses, a woman experiences symptoms of depression and anxiety.

Depressive disorder due to another medical condition. A variety of medical and neurological conditions can produce depressive symptoms; these need not meet criteria for any of the conditions above.

Substance/medication-induced depressive disorder. Alcohol or other substances (intoxication or withdrawal) can cause depressive symptoms; these need not meet criteria for any of the conditions above.

Other specified, or unspecified, depressive disorder. Use one of these categories when a patient has depressive symptoms that do not meet the criteria for the depressive diagnoses above or for any other diagnosis in which depression is a feature.

BIPOLAR AND RELATED DISORDERS

Approximately 25% of patients with mood disorders experience manic or hypomanic episodes. Nearly all of these patients will also have episodes of depression. The severity and duration of the highs and lows determine the specific bipolar disorder.

Bipolar I disorder. There must be at least one manic episode; most patients with bipolar I have also had a major depressive episode.

Bipolar II disorder. This diagnosis requires at least one hypomanic episode plus at least one major depressive episode.

Cyclothymic disorder. These patients have had repeated mood swings, but none that are severe enough to be called major depressive episodes or manic episodes.

Substance/medication-induced bipolar disorder. Alcohol or other substances (intoxication or withdrawal) can cause manic or hypomanic symptoms; these need not meet criteria for any of the conditions above.

Bipolar disorder due to another medical condition. A variety of medical and neurological conditions can produce manic or hypomanic symptoms; these need not meet criteria for any of the conditions above.

Other specified, or unspecified, bipolar disorder. Use one of these categories when a patient has bipolar symptoms that do not meet the criteria for the bipolar diagnoses above.

Other Causes of Depressive and Manic Symptoms

Schizoaffective disorder. In these patients, symptoms suggestive of schizophrenia coexist with a major depressive or a manic episode.

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.

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]. See Z63.4 [V62.82] Uncomplicated Bereavement.

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.

Specifiers

Two special sets of descriptions can be applied to a number of the mood episodes and mood disorders.

SPECIFIERS DESCRIBING CURRENT OR MOST RECENT EPISODE

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 later.)

With atypical features. These depressed patients eat a lot and gain weight, sleep excessively, and have a feeling of being sluggish or paralyzed. They are often excessively sensitive to rejection.

With melancholic features. This term applies to major depressive episodes characterized by some of the “classic” symptoms of severe depression. These patients awaken early, feeling worse than they do later in the day. They lose appetite and weight, feel guilty, are either slowed down or agitated, and do not feel better when something happens that they would normally like.

With anxious distress. A patient has symptoms of anxiety, tension, restlessness, worry, or fear that accompanies a mood episode.

With catatonic features. There are features of either motor hyperactivity or inactivity. Catatonic features can apply to major depressive episodes and to manic episodes.

With mixed features. Manic, hypomanic, and major depressive episodes may have mixtures of manic and depressive symptoms.

With peripartum onset. A manic, hypomanic, or major depressive episode (or a brief psychotic disorder) can occur in a woman during pregnancy or within a month of having a baby.

With psychotic features. Manic and major depressive episodes can be accompanied by delusions, which can be mood-congruent or -incongruent.

SPECIFIERS DESCRIBING COURSE OF RECURRING EPISODES

These specifiers describe the overall course of a mood disorder, not just the form of an individual episode.

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

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

INTRODUCTION TO MOOD EPISODES

Mood refers to a sustained emotion that colors the way we view life. Recognizing when mood is disordered is extremely important, because as many as 20% of adult women and 10% of adult men may have the experience at some time during their lives. The prevalence of mood disorders seems to be increasing in both sexes, accounting for half or more of a mental health practice. Mood disorders can occur in people of any race or socioeconomic status, but they are more common among those who are single and who have no “significant other.” A mood disorder is also more likely in someone who has relatives with similar problems.

The mood disorders encompass many diagnoses, qualifiers, and levels of severity. Although they may seem complicated, they can be reduced to a few main principles.

Years ago, the mood disorders were called affective disorders; many clinicians still use the older term, which is also entrenched in the name seasonal affective disorder. Note, by the way, that the 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. Emphasis on the actual mood experience of the patient, rather than the sometimes fuzzy concept of affect, dictates the current use of mood.

In this section, I’ll describe three types of mood episodes. You will find case vignettes illustrating each one in the sections on the mood disorders themselves, which follow.

Major Depressive Episode

Major depressive episode is one of the building blocks of the mood disorders, but it’s not a codable diagnosis. You will use it often—it is one of the most common problems for which patients seek help. Apply it carefully after considering a patient’s full history and mental status exam. (Of course, we should be careful in using every label and every diagnosis.) I mention this caution here because some clinicians tend to use the major depressive episode label almost as a reflex, without really considering the evidence. Once it gets applied, too often there is a reflexive reaching for the prescription pad.

A major depressive episode must meet five major requirements. There must be (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.

Quality of Mood

Depression is usually experienced as a mood lower than normal; patients may describe it as feeling “unhappy,” “downhearted,” “bummed,” “blue,” or many other terms expressing sadness. Several issues can interfere with the recognition of depression:

•  Not all patients can recognize or accurately describe how they feel.

•  Clinicians and patients who come from different cultural backgrounds may have difficulty agreeing that the problem is depression.

•  The presenting symptoms of depression can vary greatly from one patient to another. One patient may be slowed down and crying; another will smile and deny that anything is wrong. Some sleep and eat too much; others complain of insomnia and anorexia.

•  Some patients don’t really feel depressed; rather, they experience depression as a loss of pleasure or reduced interest in their usual activities, including sex.

•  Crucial to diagnosis is that the episode must represent a noticeable change from the patient’s usual level of functioning. If the patient does not notice it (some are too ill to pay attention or too apathetic to care), family or friends may report that there has been such a change.

Duration

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.

Symptoms

During the 2 weeks just mentioned, the patient must have at least five of the italicized symptoms below. Those five must include either depressed mood or loss of pleasure, and the symptoms must overall indicate that the person is performing at a lower level than before. Depressed mood is self-explanatory; loss of pleasure is nearly universal among depressed patients. These symptoms can be counted either if the patient reports them or if others observe that they occur.

Many patients lose appetite and weight. More than three-fourths report trouble with sleep. Typically, they awaken early in the morning, long before it is time to arise. However, some patients eat and sleep more than usual; most of these patients will qualify for the atypical featuresspecifier.

Depressed patients will usually complain of fatigue, which they may express as tiredness or low energy. Their speech or physical movements may be slowed; sometimes there is a marked pause before answering a question or initiating an action. This is called psychomotor retardation. Speech may be very quiet, sometimes inaudible. Some patients simply stop talking completely, except in response to a direct question. At the extreme, complete muteness may occur.

At the other extreme, some depressed patients feel so anxious that they become agitated. Agitation may be expressed as hand wringing, pacing, or an inability to sit still. The ability of depressed patients to evaluate themselves objectively plummets; this shows up as low self-esteem or guilt. Some patients develop trouble with concentration (real or perceived) so severe that sometimes a misdiagnosis of dementia may be made. Thoughts of death, death wishes, and suicidal ideas are the most serious depressive symptoms of all, because there is a real risk that the patient will successfully act upon them.

To count as a DSM-5 symptom for major depressive episode, 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.

In general, the more closely a patient resembles this outline, the more reliable will be the diagnosis of major depressive episode. We should note, however, that depressed patients can have many symptoms besides those listed in the DSM-5 criteria. They can include crying spells, phobias, obsessions, and compulsions. Patients may admit to feeling hopeless, helpless, or worthless. Anxiety symptoms, especially panic attacks, can be so prominent that they blind clinicians to the underlying depression.

Many patients drink more (occasionally, less) alcohol when they become depressed. This can lead to difficulty in sorting out the differential diagnosis: Which should be treated first, the depression or the drinking? (Hint: Usually, both at once.)

A small minority of patients lose contact with reality and develop delusions or hallucinations. These psychotic features can be either mood-congruent (for example, a depressed man feels so guilty that he imagines he has committed some awful sin) or mood-incongruent (a depressed person who imagines persecution by the FBI is not experiencing a typical theme of depression). Psychotic symptoms are indicated in the severity indicator (it’s verbiage you add to the diagnosis, and the final number in either the ICD-9 or ICD-10 code, as discussed later in this chapter). The case vignette of Brian Murphy includes an example.

There are three situations in which you should not count a symptom toward a diagnosis of major depressive episode:

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.

Impairment

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. Of the various consequences of mental illness, the effect on work may the hardest to detect. Perhaps this is because earning a livelihood is so important that most people will go to great lengths to hide symptoms that could threaten their employment.

Exclusions

Regardless of the severity or duration of symptoms, major depressive episode usually should not be diagnosed in the face of clinically important substance use or a general medical disorder that could cause the symptoms.

Essential Features of Major Depressive Episode

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.)

The Fine Print

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

Don’t disregard the D’s: • Duration (most of nearly every day, 2+ weeks) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders)

Coding Notes

No code alert: Major depressive episode is not a diagnosable illness; it is a building block of major depressive, bipolar I, and bipolar II disorders. It may also be found in persistent depressive disorder (dysthymia). However, certain specifier codes apply to major depressive episodes—though you tack them on only after you’ve decided on the actual mood disorder diagnosis. Relax; this will all become clear as we proceed.

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). There’s been a lot of breast beating over this move, or rather removal. Some claim that it places patients at risk for diagnosis of a mood disorder when context renders symptoms understandable; a substantial expansion in the number of people we regard as mentally ill could result.

I see the situation a little differently: We clinicians now have one fewer artificial barriers to diagnosis and treatment. However, as with any other freedom, we must use it responsibly. Evaluate the whole situation, especially the severity of symptoms, any previous history of mood disorder, the timing and severity of putative precipitant (bereavement plus other forms of loss), and the trajectory of the syndrome (is it getting worse or better?). And reevaluate frequently.

I’ve included examples of major depressive episode in the following vignettes: Brian Murphy, Elizabeth Jacks, Winona Fisk, Iris McMaster, Noah Sanders, Sal Camozzi, and Aileen Parmeter. In addition, there may be some examples in Chapter 20, “Patients and Diagnoses”—but you’ll have to find them for yourself.

Manic Episode

The second “building block” of the mood disorders, manic episode, has been recognized for at least 150 years. The classic triad of manic symptoms consists of heightened self-esteem, increased motor activity, and pressured speech. These symptoms are obvious and often outrageous, so manic episode is not often overdiagnosed. However, the psychotic symptoms that sometimes attend manic episode can be so florid that clinicians instead diagnose schizophrenia. This tendency to misdiagnosis may have decreased since 1980, when the DSM-III criteria increased clinicians’ awareness of bipolar illness. The introduction of lithium treatment for bipolar disorders in 1970 also helped promote the diagnosis.

Manic episode is much less common than major depressive episode, perhaps affecting 1% of all adults. Men and women are about equally likely to have mania.

The features that must be present in order to diagnose manic episode are identical to those for major depressive episode: (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.

Quality of Mood

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.

Duration

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

Symptoms

In addition to the change in mood (euphoria or irritability), the patient must also have an increase in energy or activity level during a 1-week period. With these changes, at least three of the italicized symptoms listed below must also be present to an important degree during the same time period. (Note that if the patient’s abnormal mood is only irritable—that is, without any component of euphoria—four symptoms are required in addition to the increased activity level.)

Heightened self-esteem, found in most patients, can become grandiose to the point that it is delusional. Then patients believe that they can advise presidents and solve the problem of world hunger, in addition to more mundane tasks such as conducting psychotherapy and running the very medical facilities that currently house them. Because such delusions are in keeping with the euphoric mood, they are called mood-congruent.

Manic patients typically report feeling rested on little sleep. Time spent sleeping seems wasted; they prefer to pursue their many projects. In its milder forms, this heightened activity may be goal-directed and useful; patients who are only moderately ill can accomplish quite a lot in a 20-hour day. But as they become more and more active, agitation ensues, and they may begin many projects they never complete. At this point they have lost judgment for what is reasonable and attainable. They may become involved in risky business ventures, indiscreet sexual liaisons, and questionable religious or political activities.

Manic patients are eager to tell anyone who will listen about their ideas, plans, and work, and they do so in speech that is loud and difficult to interrupt. Manic speech is often rapid and pressured, as if there were too many dammed-up words trying to escape through a tiny nozzle. The resulting speech may exhibit what is called flight of ideas, in which one thought triggers another to which it bears only a marginally logical association. As a result, a patient may wander far afield from where the conversation (or monologue) started. Manic patients may also be easily distracted by irrelevant sounds or movements that other people would ignore.

Some manic patients retain insight and seek treatment, but many will deny that anything is wrong. They rationalize that no one who feels this well or is so productive could possibly be ill. Manic behavior therefore continues until it ends spontaneously or the patient is hospitalized or jailed. I consider manic episodes to be acute emergencies, and I don’t expect many clinicians will argue.

Some symptoms not specifically mentioned in the DSM-5 criteria are also worth noting here.

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.

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.

What about episodes that don’t start until the patient undergoes treatment for a depression? Should they count as fully as evidence of spontaneous mania or hypomania? 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. This declaration nicely rounds out the list of possibilities: DSM-IV stated flatly that manic episodes caused by treatment could not count toward a diagnosis of bipolar I disorder, whereas DSM-III-R implied that they could. And DSM-III kept silent on the whole matter.

The authors of the successive DSMs may have been thinking of Emerson’s famous epigram: A foolish consistency is the hobgoblin of little minds.

Impairment

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.

Exclusions

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.

Essential Features of Manic Episode

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.

The Fine Print

The D’s: • 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)

Coding Notes

Manic episode is not a diagnosable illness; it is a building block of bipolar I disorder.

Elisabeth Jacks had a manic episode; you can read her history beginning on page 131. Another example is that of Winona Fisk. Look for other cases in the patient histories given in Chapter 20.

Hypomanic Episode

Hypomanic episode is the final mood disorder “building block.” Comprising most of the same symptoms as manic episode, it is “manic episode writ small.” Left without treatment, some patients with hypomanic episode may become manic later on. But many, especially those who have bipolar II disorder, have repeated hypomanic episodes. Hypomanic episode isn’t codable as a diagnosis; it forms the basis for bipolar II disorder, and it can be encountered in bipolar I disorder, after the patient has already experienced an episode of actual mania. 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.

TABLE 3.1. Comparing Manic and Hypomanic Episodes

aFour or more if the only abnormality of mood is irritability.
bBoth manic and hypomanic episodes can have the specifier with mixed features.

Quality of Mood

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.

Duration

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

Symptoms

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.

Impairment

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.

Exclusions

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.

Essential Features of Hypomanic Episode

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!

The Fine Print

The D’s: • 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)

Coding Notes

Specify if: With mixed features.

There is no severity code.

Hypomanic episode is not a diagnosable illness; it is a building block of bipolar II disorder and bipolar I disorder.

MOOD DISORDERS BASED ON THE MOOD EPISODES

From this point, the format of my presentation differs somewhat from both that of the DSM-5 and that of the Quick Guide at the beginning of the chapter. First, I’ll discuss the mood disorders that use the mood episode “building blocks”—major depressive disorder and bipolar I and II disorders. Afterwards, I’ll cover the disorders that do not crucially involve these episodes.

Major Depressive Disorder

A patient who has one or more major depressive episodes, and no manic or hypomanic symptoms, is said to have major depressive disorder (MDD). It is a common condition, affecting about 7% of the general population, with a female preponderance of roughly 2:1. MDD usually begins in the middle to late 20s, but it can occur at any time of life, from childhood to old age. The onset may be sudden or gradual. Although episodes last on average from 6 to 9 months, the range is enormous, from a few weeks to many years. Recovery usually begins within a few months of onset, though that too can vary enormously. A full recovery is less likely for a person who has a personality disorder or symptoms that are more severe (especially psychotic features). MDD is strongly hereditary; first-degree relatives have a risk several times that of the general population.

Some patients have only a single episode during an entire lifetime; then they are diagnosed with (no surprise) MDD, single episode. However, roughly half the patients who have one major depressive episode will have another. At the point they develop a second episode (to count, it must be separated from the first by at least 2 months), we must change the diagnosis to MDD, recurrent type.

For any given patient, symptoms of depression remain pretty much the same from one episode to the next. These patients will have an episode roughly every 4 years; there is some evidence that the frequency of episodes increases with age. Multiple episodes of depression greatly increase the likelihood of suicide attempts and completed suicide. Unsurprisingly, patients with recurrent episodes are also much more likely than those with a single episode to be impaired by their symptoms. One of the most severe consequences is suicide, which is the fate of about 4% of patients with MDD.

Perhaps 25% of patients with MDD will eventually experience a manic or hypomanic episode, thereby requiring yet another change in diagnosis—this time to bipolar (I or II) disorder. We’ll talk more about them later.

Essential Features of Major Depressive Disorder, {Single Episode}{Recurrent}

The patient has {one}{or more} major depressive episodes and no spontaneous episodes of mania or hypomania.

The Fine Print

Two months or more without symptoms must intervene for episodes to be counted as separate.

Decide on the D’s: • Differential diagnosis (substance use and physical disorders, other mood disorders, ordinary grief and sadness, schizoaffective disorder)

Coding Notes

From type of episode and severity, find code numbers in Table 3.2. If applicable, choose specifiers from Table 3.3.

TABLE 3.2. Coding for Bipolar I and Major Depressive Disorders

Note. Here are two examples of how you put it together: Bipolar I disorder, manic, severe with mood-congruent psychotic features, with peripartum onset, with mixed features. Major depressive disorder, recurrent, in partial remission, with seasonal pattern. Note the order: name → episode type → severity/psychotic/remission → other specifiers. Purchasers of this ebook can download a copy of this table from www.guilford.com/morrison2-forms.
aIf the bipolar I type isn’t specified, code as F31.9 [296.7].
bMild. Meets the minimum of symptoms, which are distressing but interfere minimally with functionality.
cModerate. Intermediate between mild and severe.
dSevere. Many serious symptoms that profoundly impede patient’s functioning.
eIf psychotic features are present, use these code numbers regardless of severity (it will almost always be severe, anyway). Record these features as mood-congruent or mood-incongruent.
fPartial remission. Symptoms are no longer sufficient to meet criteria.
gFull remission. For 2 months or more, the patient has been essentially free of symptoms.

TABLE 3.3. Descriptors and Specifiers That Can Apply to Mood Disorders

Note. This table can help you to choose the sometimes lengthy string of names, codes, and modifiers for the mood disorders. Start reading from left to right in the table, putting in any modifiers that apply in the order you come to them. Dysthymia can also have early or late onset, plus a variety of additional specifiers. 
aThe catatonia specifier requires its own line of code and description. (See p. 100.) Purchasers of this ebook can download a copy of this table from www.guilford.com/morrison2-forms.

Brian Murphy

Brian Murphy had inherited a small business from his father and built it into a large one. When he sold out a few years later, he invested most of his money; with the rest, he bought a small almond farm in northern California. With his tractor, he handled most of the farm chores himself. Most years the farm earned a few hundred dollars, but as Brian was fond of pointing out, it really didn’t make much difference. If he never made a dime, he felt he got “full value from keeping busy and fit.”

When Brian was 55, his mood, which had always been normal, slid into depression. Farm chores seemed increasingly to be a burden; his tractor sat idle in its shed.

As his mood blackened, Brian’s body functioning seemed to deteriorate. Although he was constantly fatigued, often falling into bed by 9 P.M., he would invariably awaken at 2 or 3 A.M. Then obsessive worrying kept him awake until sunrise. Mornings were worst for him. The prospect of “another damn day to get through” seemed overwhelming. In the evenings he usually felt somewhat better, though he’d sit around working out sums on a magazine cover to see how much money they’d have if he “couldn’t work the farm” and they had to live on their savings. His appetite deserted him. Although he never weighed himself, he had to buckle his belt two notches smaller than he had several months before.

“Brian just seemed to lose interest,” his wife, Rachel, reported the day he was admitted to the hospital. “He doesn’t enjoy anything any more. He spends all his time sitting around and worrying about being in debt. We owe a few hundred dollars on our credit card, but we pay it off every month!”

During the previous week or two, Brian had begun to ruminate about his health. “At first it was his blood pressure,” Rachel said. “He’d ask me to take it several times a day. I still work part-time as a nurse. Several times he thought he was having a stroke. Then yesterday he became convinced that his heart was going to stop. He’d get up, feel his pulse, pace around the room, lie down, put his feet above his head, do everything he could to ‘keep it going.’ That’s when I decided to bring him here.”

“We’ll have to sell the farm.” That was the first thing Brian said to the mental health clinician when they met. Brian was casually dressed and rather rumpled. He had prominent worry lines on his forehead, and he kept feeling for his pulse. Several times during the interview, he seemed unable to sit still; he would get up from the bed where he was sitting and pace over to the window. His speech was slow but coherent. He talked mostly about his feelings of being poverty-stricken and his fears that the farm would have to go on the block. He denied having hallucinations, but admitted to feeling tired and “all washed up—not good for anything any more.” He was fully oriented, had a full fund of information, and scored a perfect 30 on the MMSE. He admitted that he was depressed, but he denied having thoughts about death. Somewhat reluctantly, he agreed that he might need treatment.

Rachel pointed out that with his generous disability policy, his investments, and his pension from his former company, they had more money coming in than when he was healthy.

“But still we have to sell the farm,” Brian replied.

Evaluation of Brian Murphy

Unfortunately, clinicians (including some mental health specialists) commonly make two sorts of mistakes when evaluating patients with depression.

First, we sometimes focus too intently on a patient’s anxiety, alcohol use, or psychotic symptoms and ignore underlying symptoms of depression or dysthymia. Here’s my lifelong rule, formulated from bitter experience (not all mine) as far back as when I was a resident: Always look for a mood disorder in any new patient, even if the chief complaint is something else.

Second, the presenting depressive or manic symptoms can be quite noticeable, even dramatic—to the point that clinicians may fail to notice, lurking underneath, the presence of alcohol use disorder or another disorder (good examples are neurocognitive and somatic symptom disorders). And that suggests another, equally important rule, almost the mirror image of the first rule: Never assume that a mood disorder is your patient’s only problem.

First, let’s try to identify the current (and any previous) mood episodes. Brian Murphy had been ill much longer than 2 weeks (criterion A). Of the major depressive episode symptoms listed (five are required by DSM-5), he had at least six: low mood (A1), loss of interest (A2), fatigue (A6), sleeplessness (A4), low self-esteem (A7), loss of appetite (A3), and agitation (A5). (Note that either low mood or loss of interest is required for diagnosis; Brian had both.) He was so seriously impaired (B) that he required hospitalization. Although we do not have the results of his physical exam and laboratory testing, the vignette provides no history that would suggest another medical condition (for example, pancreatic carcinoma) or substance use (C). However, his clinician would definitely need to ask both Brian and his wife about this—depressed people often increase their drinking. He was clearly severely depressed and different from his usual self. He easily fulfilled the criteria for major depressive episode.

Next, what type of mood disorder did Brian have? There had been no manic or hypomanic episodes (E), ruling out bipolar I or II disorder.His delusions of poverty could suggest a psychotic disorder (such as schizoaffective disorder), but he had too few psychotic symptoms, and the timing of mood symptoms versus delusions was wrong (D). He was deluded but had no additional A criteria for schizophrenia. His mood symptoms ruled out brief psychotic disorder and delusional disorder. He therefore fulfilled the requirements for MDD.

There are just two subtypes of MDD: single episode and recurrent. Although Brian Murphy might subsequently have other episodes of depression, this was the only one so far.

For the further description and coding of Brian Murphy’s depression, let’s turn to Table 3.2. His single episode dictates the column to highlight under MDD. And he was delusional, so we’d code him as with psychotic features.

But wait: Suppose he hadn’t been psychotic? What severity would we assign him then? Despite the fact that he wasn’t suicidal (he didn’t want death; rather, he feared it), he did have most of the required symptoms, and he was seriously impaired by his depressive illness. That’s why I’d rate him as severely depressed (but remember, the code number has already been determined).

Now we’ll turn to the panoply of other specifiers, which I’ll discuss toward the end of this chapter. Brian had no manic symptoms; that rules out with mixed features. His delusion that he was poor and would have to sell the farm was mood-congruent—that is, in keeping with the usual cognitive themes of depression. (However, the thought that his heart would stop and the pulse checking were probably not delusional. I’d regard them as signifying the overwhelming anxiety he felt about the state of his health.) The words we’d attach to his diagnosis (so far) would be MDD, single episode, severe with mood-congruent psychotic features.

But wait; there’s more. There were no abnormalities of movement suggestive of catatonic features, nor did his depression have any atypical features (for example, he didn’t have increased appetite or sleep too much). Of course, he would not qualify for peripartum onset. But his wife complained that he didn’t “enjoy anything any more,” suggesting that he might qualify for melancholic features. He was agitated when interviewed (marked psychomotor slowing would have also qualified for this criterion), and he had lost considerable weight. He reported awakening early on many mornings (terminal insomnia). The interviewer did not ask him whether this episode of depression differed qualitatively from how he felt when his parents died, but I’d bet that it did. So, we’ll add with melancholic features to the mix.

I wrote this vignette before a new specifier, with anxious distress, was a gleam in anyone’s eye, but I think Brian Murphy qualifies for it as well. He appeared edgy and tense, and he was markedly restless. Furthermore, he seemed to be expressing the fear that something horrible—possibly a catastrophic health event—would occur. Even though nothing was said about poor concentration, he had at least three of the symptoms required for the with anxious distress specifier, at a moderate severity rating. The evidence is that this specifier has real prognostic importance, suggesting, in the absence of treatment, the possibility of a poor outcome—even suicide.

Some patients with severe depression also report many of the symptoms typical of panic disorder, generalized anxiety disorder, or some other anxiety disorder. In such a case, two diagnoses could be made. Usually the mood disorder is listed first as the primary diagnosis. Anxiety symptoms that do not fulfill criteria for one of the disorders described in Chapter 4 may be further evaluated as evidence for the anxious distress specifier.

Of course, Brian wouldn’t qualify for rapid cycling or seasonal pattern; with only one episode, there could be no pattern. I’d give him a GAF score of 51, and his final diagnosis would be as given below.

Let me just say that the prospect of using so many different criteria sets to code one patient may seem daunting, but taking it one step at a time reveals a process that is really quite logical and (once you get the hang of it) fairly quick. The same basic methods should be applied to all examples of depression. (Of course, you could argue—I certainly would—that using the prototypical descriptions of depression and mania and their respective disorders simplifies things still further. But again, remember always to consider the possibility of substance use and physical causes of any given symptom set.)

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. 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.

Aileen Parmeter

“I just know it was a terrible mistake to come here.” For the third time, Aileen Parmeter got out of her chair and walked to the window. A wiry 5 feet 2 inches, this former Marine master sergeant (she had supervised a steno pool) weighed a scant 100 pounds. Through the slats of the Venetian blinds, she peered longingly at freedom in the parking lot below. “I just don’t know whatever made me come.”

“You came because I asked you to,” her clinician explained. “Your nephew called and said you were getting depressed again. It’s just like last time.”

“No, I don’t think so. I was just upset,” she explained patiently. “I had a little cold for a few days and couldn’t play my tennis. I’ll be fine if I just get back to my little apartment.”

“Have you been hearing voices or seeing things this time?”

“Well, of course not.” She seemed rather offended. “You might as well ask if I’ve been drinking.”

After her last hospitalization, Aileen had been well for about 10 months. Although she had taken her medicine for only a few weeks, she had remained active until 3 weeks ago. Then she stopped seeing her friends and wouldn’t play tennis because she “just didn’t enjoy it.” She worried constantly about her health and had been unable to sleep. Although she didn’t complain of decreased appetite, she had lost about 10 pounds.

“Well, who wouldn’t have trouble? I’ve just been too tired to get my regular exercise.” She tried to smile, but it came off crooked and forced.

“Miss Parmeter, what about the suicidal thoughts?”

“I don’t know what you mean.”

“I mean, each time you’ve been here—last year, and 2 years before that—you were admitted because you tried to kill yourself.”

“I’m going to be fine now. Just let me go home.”

But her therapist, whose memory was long, had ordered Aileen held for her own protection in a private room where she could be observed one-on-one.

Sleepless still at 3 A.M., Aileen got up, smiled wanly at the attendant, and went in to use the bathroom. Looping a strip she had torn from her sweatsuit over the top of the door, she tried to hang herself. As the silence lengthened, the attendant called out softly, then tapped on the door, then opened it and sounded the alarm. The code team responded with no time to spare.

The following morning, the therapist was back at her bedside. “Why did you try to do that, Miss Parmeter?”

“I didn’t try to do anything. I must have been confused.” She gingerly touched the purple bruises that ringed her neck. “This sure hurts. I know I’d feel better if you’d just let me go home.”

Aileen remained hospitalized for 10 days. Once her sore neck would allow, she began to take her antidepressant medication again. Soon she was sleeping and eating normally, and she made a perfect score on the MMSE. She was released to go home to her apartment and her tennis, still uncertain why everyone had made such a fuss about her.

Evaluation of Aileen Parmeter

Aileen never acknowledged feeling depressed, but she had lost interest in her usual activities. This change had lasted longer than 2 weeks, and—as in previous episodes—her other symptoms included fatigue, insomnia, loss of weight, and suicidal behavior (criterion A). (Although she reproached herself for entering the hospital, these feelings referred exclusively to her being ill and would not be scored as guilt.) She was sick enough to require hospitalization, fulfilling the impairment criterion (B).

Aileen could have a mood disorder due to another medical condition, and this would have to be pursued by her clinician, but the history of recurrence makes this seem unlikely (C). Symptoms of apathy and poor memory raise the question of mild neurocognitive disorder, but her MMSE showed no evidence of memory impairment. She denied alcohol consumption, so a substance-induced mood disorder would also appear unlikely (her clinician had known her for so long that further pursuit of the possibility would be wasted effort).

There was no evidence that Aileen had ever had mania or hypomania, ruling out bipolar I or II disorder (E), and absence of any psychotic symptoms rules out psychotic disorders (D). She therefore fulfills the criteria for MDD. She’d had more than one episode separated by substantially longer than 2 months, which would satisfy the requirement for the term recurrent. Turning to Table 3.2, we can reject the rows there describing psychotic features (she emphatically denied having delusions or hallucinations) and remission.

Now we must consider the severity of her depression. It is always a problem how best to score someone with so little insight. Even with the suicide attempt, Aileen appeared barely to meet the five symptoms needed for major depressive episode. According to the rules, she should receive a severity coding of no greater than moderate. However, for a patient who has just nearly killed herself, this would be inaccurate and possibly dangerous; one of her symptoms, suicidal behavior, was very serious indeed. As I’ve said before, the coding instructions are meant to be guides, not shackles: I’d call Aileen’s depression severe.

She wouldn’t qualify for any of the specifiers for the most recent episode—perhaps because her lack of insight prevented her from providing full information. (I suppose that longer observation might reveal criteria adequate for with melancholic features.)

Other diagnoses are sometimes found in patients with MDD. These include several of the anxiety disorders, obsessive–compulsive disorder, and the substance-related disorders (especially alcohol use disorder). There is no evidence for any of these. I’d give her a GAF score of only 15 on admission. Her GAF had improved to 60 by the time she was released. Her complete diagnosis would be as follows:

Bipolar I Disorder

Bipolar I disorder is shorthand for any cyclic mood disorder that includes at least one manic episode. Although this nomenclature has only been adopted within the past several decades, bipolar I disorder has been recognized for over a century. Formerly, it was called manic–depressive illness; older clinicians may still refer to it this way. Men and women are about equally affected, for a total of approximately 1% of the general adult population. Bipolar I disorder is strongly hereditary.

There are two technical points to consider in evaluating episodes of bipolar I disorder. First, for an episode to count as a new one, 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.

Second, a manic or hypomanic episode will occasionally seem to be precipitated by the treatment of a depression. Antidepressant drugs, ECT, or bright light (used to treat seasonal depression) may cause a patient to move rapidly from depression into a full-blown manic episode. Bipolar I disorder is defined by the occurrence of spontaneous depressions, manias, and hypomanias; therefore, any treatment-induced manic or hypomanic episode 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.

In addition, 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. Because the longitudinal course of bipolar I disorder differs strikingly from those of the psychotic disorders, this should only rarely cause diagnostic problems.

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. The depressive symptoms will be very much like those in the major depressive disorders of Brian Murphy and Aileen Parmeter. Elisabeth Jacks, whose current episode was manic, had been depressed a few weeks before her current evaluation.

In a given patient, symptoms of mood disorder tend to remain the same from one episode to the next. However, it is possible that after an earlier manic episode, a subsequent mood upswing may be less severe, and therefore only hypomanic. (The first episode of a bipolar I disorder couldn’t be hypomanic; otherwise, you’d have to diagnose bipolar II.) Although I have provided no vignette for bipolar I, most recent episode hypomanic, I have described a hypomanic episode in the case of Iris McMaster, a patient with bipolar II disorder.

Researchers who have followed bipolar patients for many years report that some have only manias. The concept of unipolar mania has been debated off and on for a long time. There are probably some patients who will never have a depression, but most will, given enough time. I have known of patients who had as many as seven episodes of mania over a 20-year period before finally having a first episode of depression. What’s important here is that all patients with bipolar I (and II) disorder—and their families—should be warned to watch out for depressive symptoms. Bipolar I patients have a high likelihood of completing suicide; some reports suggest that these people account for up to a quarter of all suicides.

Essential Features of Bipolar I Disorder

The patient has had at least one manic episode, plus any number (including zero) of hypomanic and major depressive episodes.

The Fine Print

A manic episode that was precipitated by treatment (medication, ECT, light therapy) can be counted toward a diagnosis of bipolar I disorder if the manic symptoms last beyond the expected physiological treatment effects.

The D’s: • Differential diagnosis (substance use and physical disorders, other bipolar disorders, psychotic disorder)

Coding Notes

From type of episode and severity, find code numbers in Table 3.2. Finally, choose from a whole lot of specifiers in Table 3.3.

Older patients who develop a mania for the first time may have a comorbid neurological disorder. They may also have a higher mortality. First-episode mania in the elderly may be quite a different illness from recurrent mania in the elderly, and should probably be given a different diagnosis, such as unspecified bipolar disorder.

Elisabeth Jacks

Elisabeth Jacks ran a catering service with her second husband, Donald, who was the main informant.

At age 38, Elisabeth already had two grown children, so Donald could understand why this pregnancy might have upset her. Even so, she had seemed unnaturally sad. From about her fourth month, she spent much of each day in bed, not arising until afternoon, when she began to feel a little less tired. Her appetite, voracious during her first trimester, fell off, so that by the time of delivery she was several pounds lighter than usual for a full-term pregnancy. She had to give up keeping the household and business accounts, because she couldn’t focus her attention long enough to add a column of figures. Still, the only time Donald became really alarmed was one evening at the beginning of Elisabeth’s ninth month, when she told him that she had been thinking for days that she wouldn’t survive childbirth and he would have to rear the baby without her. “You’ll both be better off without me, anyway,” she had said.

After their son was born, Elisabeth’s mood brightened almost at once. The crying spells and the hours of rumination disappeared; briefly, she seemed almost her normal self. Late one Friday night, however, when the baby was 3 weeks old, Donald returned from catering a banquet to find Elisabeth wearing only bra and panties and icing a cake. Two other just-iced cakes were lined up on the counter, and the kitchen was littered with dirty pots and pans.

“She said she’d made one for each of us, and she wanted to party,” Donald told the clinician. “I started to change the baby—he was howling in his basket—but she wanted to drag me off to the bedroom. She said ‘Please, sweetie, it’s been a long time.’ I mean, even if I hadn’t been dead tired, who could concentrate with the baby crying like that?”

All the next day, Elisabeth was out with girlfriends, leaving Donald home with the baby. On Sunday she spent nearly $300 for Christmas presents at an April garage sale. She seemed to have boundless energy, sleeping only 2 or 3 hours a night before arising, rested and ready to go. On Monday she decided to open a bakery; by telephone, she tried to charge over $1,600 worth of kitchen supplies to their Visa card. She’d have done the same the next day, but she talked so fast that the person she called couldn’t understand her. In frustration, she slammed the phone down.

Elisabeth’s behavior became so erratic that for the next two evenings Donald stayed off work to care for the baby, but his presence only seemed to provoke her sexual demands. Then there was the marijuana. Before Elisabeth became pregnant, she would have an occasional toke (she called it her “herbs”). During the past week, not all the smells in the house had been fresh-baked cake, so Donald thought she might be at it again.

Yesterday Elisabeth had shaken him awake at 5 A.M. and announced, “I am becoming God.” That was when he had made the appointment to bring her for an evaluation.

Elisabeth herself could hardly sit still during the interview. In a burst of speech, she described her renewed energy and plans for the bakery. She volunteered that she had never felt better in her life. In rapid succession she then described her mood (ecstatic), how it made her feel when she put on her best silk dress (sexy), where she had purchased the dress, how old she had been when she bought it, and to whom she was married at the time.

Patients who may have bipolar I disorder need a careful interview for symptoms of addiction to alcohol; alcohol use disorder is diagnosed as a comorbid disorder in as many as 30%. Often the alcohol-related symptoms appear first.

Evaluation of Elisabeth Jacks

This vignette provides a fairly typical picture of manic excitement. Elisabeth Jacks’s mood was definitely elevated. Aside from the issue of marijuana smoking (which appeared to be a symptom, not a cause), her relatively late age of onset was the only atypical feature.

For at least a week Elisabeth had had this high mood (manic episode criterion A), accompanied by most of the other typical symptoms (B): reduced need for sleep (B2), talkativeness (B3), flight of ideas (a sample run is given at the end of the vignette, B4), and poor judgment (buying Christmas gifts at the April garage sale—B7). Her disorder caused considerable distress, for her family if not for her (C); this is usual for patients with manic episode. The severity of the symptoms (not their number or type) and the degree of impairment were what would differentiate her full-blown manic episode from a hypomanic episode.

The issue of another medical condition (D) is not addressed in the vignette. Medical problems such as hyperthyroidism, multiple sclerosis, and brain tumors would have to be ruled out by the admitting clinician before a definitive diagnosis could be made. Delirium must be ruled out for any postpartum patient, but she was able to focus her attention well. Although Elisabeth may have been smoking marijuana, misuse of this substance should never be confused with mania; neither cannabis intoxication nor withdrawal presents the combination of symptoms typical of mania. Although the depression that occurred early in her pregnancy would have met the criteria for major depressive episode, her current manic episode would obviate major depressive disorder. Because the current episode was too severe for hypomanic symptoms, she could not have cyclothymic disorder. Therefore, the diagnosis would have to be bipolar I disorder (because she was hospitalized, it could not be bipolar II). The course of her illness was not compatible with any psychotic disorder other than brief psychotic disorder, and that diagnosis specifically excludes a bipolar disorder (B).

The bipolar I subtypes, as described earlier, are based upon the nature of the most recent episode. Elisabeth’s, of course, would be current episode manic.

Next we’ll score the severity of Elisabeth’s mania (see the footnotes to Table 3.2). These severity codes are satisfactorily self-explanatory, though there’s one problem: Whether Elisabeth was actually psychotic is not made clear in the vignette. If we take her words literally, she thought she was becoming God, in which case she would qualify for severe with psychotic features. These would be judged mood-congruent because grandiosity was in keeping with her exalted mood.

The only possible episode specifier (Table 3.3) would be with peripartum onset: She developed her manic episode within a few days of delivery. With a GAF score of 25, the full diagnosis would be as follows:

Winona Fisk

By the time she was 21, Winona Fisk had already had two lengthy mental health hospitalizations, one each for mania and depression. Then she remained well for a year on maintenance lithium, which in the spring of her junior year in college she abruptly discontinued because she “felt so well.” When two of her brothers brought her to the hospital 10 days later, she had been suspended for repeatedly disrupting classes with her boisterous behavior.

On the ward, Winona’s behavior was mostly a picture of manic excitement. She spoke nonstop and was constantly on the move, often rummaging through other patients’ purses and lockers. But many of the thoughts flooding her mind were so sad that for 8 or 10 days she often spontaneously wept for several minutes at a time. She said she felt depressed and guilty—not for her behavior in class, but for being such a burden to her family. During these brief episodes, she claimed to hear the heart of her father beating from his grave, and she would express the wish to join him in death. She ate little and lost 15 pounds; she often awakened weeping at night and was unable to get back to sleep.

Nearly a month’s treatment with lithium, carbamazepine, and neuroleptics was largely futile. Her mood disorder eventually yielded to six sessions of bilateral ECT.

Evaluation of Winona Fisk

Winona’s two previous episodes of bipolar I disorder make that diagnosis crystal clear. Our only remaining task is to decide about the type and severity of the most recent episode.

In a typical manner, Winona’s manic episode began with feeling “too good” to be ill; that got her into trouble with her lithium. Her symptoms, which included poor judgment (she was suspended from class for her behavior), talkativeness, and increased psychomotor activity fulfilled criteria A and B for manic episode; hospitalization (C) ruled out hypomanic episode. (Her clinician would have to make sure she had no other medical or substance use disorder—criterion D.)

But at times throughout the day, she also had “microdepressions” during which she experienced at least three depressive symptoms, which would fulfill the criterion A requirements for the specifier with mixed features (manic episode): She felt depressed (A1), she expressed feelings of (inappropriate) guilt (A5), and she ruminated about death (A6). We cannot include her problems with sleep and appetite/weight; because they are found in both manic and depressive episodes, they don’t make the mixed features list. She didn’t meet full major depressive criteria, so there’s no need to fuss about whether to call her episode manic with mixed features, or major depressive with mixed features (C). And she didn’t drink or use drugs (D).

The severity of Winona’s episode should be judged on the basis of both the symptom count and the degree to which her illness affected her (and others). All things considered, her clinician felt that she was seriously ill, and coded her accordingly.

With a GAF score of 25, here’s Winona’s diagnosis:

F31.81 [296.89] Bipolar II Disorder

The symptoms of bipolar II and bipolar I disorders have important similarities. The principal distinction, however, is the degree of disability and discomfort conferred by the high phase, which in bipolar II never involves psychosis and never requires hospitalization.* Bipolar II disorder consists of recurrent major depressive episodes interspersed with hypomanic episodes.

Like bipolar I disorder, bipolar II may be diagnosed on the basis of mood episodes that arise spontaneously or that are precipitated by antidepressants, ECT, or bright light therapy—if the induced symptoms subsequently last past the expected duration of the physiological treatment effects. (Be sure to ask the patient and informants whether there has been another hypomanic episode that was not precipitated by treatment; many patients will have had one.) Bipolar II is also associated with an especially high rate of rapid cycling, which carries added risk for a difficult course of illness.

Women may be more prone than men to develop bipolar II disorder (the sexes are about equally represented in bipolar I disorder); fewer than 1% of the general adult population are affected, though the prevalence among adolescents may be higher. The peripartum period may be especially likely to precipitate an episode of hypomania.

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.

It is important to note that although I have earlier described hypomanic episode as “mania lite,” we shouldn’t imagine that the disorder is innocuous. Indeed, some studies suggest that patients with bipolar II are ill longer and spend more time in the depressive phase than is the case for patients with bipolar I. They may also be especially likely to make impulsive suicide attempts. And not a few (in the 10% range) will eventually experience a full-blown manic episode.

Sal Camozzi was another patient with bipolar II disorder; his history is given in Chapter 11.

Essential Features of Bipolar II Disorder

The patient has had at least one each of a major depressive episode and a hypomanic episode, but no manic episodes ever.

The Fine Print

The 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

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).

Iris McMaster

“I’m a writer,” said Iris McMaster. It was her first visit to the interviewer’s office, and she wanted to smoke. She fiddled with a cigarette but didn’t seem to know what to do with it. “It’s what I do for a living. I should be home doing it now—it’s my life. Maybe I’m the finest creative writer since Dostoevsky. But my friend Charlene said I should come in, so I’ve taken time away from working on my play and my comic novel, and here I am.” She finally put the cigarette back into the pack.

“Why did Charlene think you should come?”

“She thinks I’m high. Of course I’m high. I’m always high when I’m in my creative phase. Only she thinks I’m too nervous.” Iris was slender and of average height; she wore a bright pink spring outfit. She looked longingly at her pack of cigarettes. “God, I need one of those.”

Her speech could always be interrupted, but it was salted with bon mots, neat turns of phrase, and original similes. But Iris was also able to give a coherent history. At 45, she was married to an engineer and had a daughter who was nearly 18. And she really was a writer, who over the last several years had sold (mainly to women’s magazines) articles about a variety of subjects.

For 3 or 4 months Iris had been in one of her high phases, cranking out an enormous volume of essays on wide-ranging topics. Her “wired” feeling was uncomfortable in a way, but it hadn’t troubled her because she felt so productive. Whenever she was creating, she didn’t need much sleep. A 2-hour nap would leave her rested and ready for another 10 hours at her computer. At those times, her husband would fix his own meals and kid her about having “a one-track mind.”

Iris never ate much during her high phases, so she lost weight. But she didn’t get herself into trouble: no sexual indiscretions, no excessive spending (“I’m always too busy to shop”). And she volunteered that she had never “seen visions, heard voices, or had funny ideas about people following me around.” She had never spent time “in the funny farm.”

As Iris paused to gather her thoughts, her fingers clutched the cigarette package. She shook her head almost imperceptibly. Without uttering another word, she grabbed her purse, arose from the chair, and swooped out the door. It was the last the interviewer saw of her for a year and a half.

In November of the following year, a person announcing herself as Iris McMaster dropped into that same office chair. She seemed like an impostor. She’d gained 30 or 40 pounds, which she had stuffed into polyester slacks and a bulky knit sweater. “As I was saying,” were the first words she uttered. Just for a second, the corners of her mouth twitched up. But for the rest of the hour she soberly talked about her latest problem: writer’s block.

About a year ago, she had finished her play and was well into her comic novel when the muse deserted her. For months now, she had been arising around lunchtime and spending long afternoons staring at her computer. “Sometimes I don’t even turn it on!” she said. She couldn’t focus her thinking to create anything that seemed worth clicking on “save.” Most nights she tumbled into bed at 9. She felt tired and heavy, as though her legs were made of bricks.

“It’s cheesecake, actually,” was how Iris described her weight gain. “I have it delivered. For months I haven’t been interested enough to cook for myself.” She hadn’t been suicidal, but the only time she felt much better was when Charlene took her out to lunch. Then she ate and made conversation pretty much as she used to. “I’ve done that quite a lot recently, as anyone can see.” Once she returned home, the depression flooded back.

Finally, Iris apologized for walking out a year and a half earlier. “I didn’t think I was the least bit sick,” she said, “and all I really wanted to do was get back to my computer and get your character on paper!”

Evaluation of Iris McMaster

This discussion will focus on the episode of elevated mood Iris had during her first visit. There are two possibilities for such an episode: manic and hypomanic. As far as the time requirement was concerned, either type was possible—hypomanic requires 4 days (hypomanic episode criterion A), manic 1 week. She admitted that she felt “wired,” and this feeling had apparently been sustained for several months. It was also abnormal for her. During her high phase, she had at least four symptoms (three required, B): high self-esteem, decreased need for sleep, talkativeness, and increased goal-directed activity (writing).

The mood of either a manic or hypomanic episode is excessively high or irritable, and it is accompanied by increased energy and activity. The real distinction between hypomania and mania consists in the effects of the mood elevation on patient and surroundings. The patient’s functioning during a manic episode is markedly impaired, whereas in a hypomanic episode it is only a clear change from normal for the individual (C) that others can notice (D). During her high spells, Iris’s writing productivity actually increased, and her social relationships (those with her husband and friends, though perhaps not with her hapless clinician) did not appear to suffer (E). Note that the collective effect of criteria C, D, and E is to allow some impairment of functioning, just not very much.

Assuming that Iris had no other medical conditions or substance-induced mood disorder (F), she could have one of these three: bipolar I, bipolar II, or cyclothymic disorder. Judging from her lack of psychosis and hospitalizations, Iris had never had a true mania, ruling out bipolar I disorder. Her mood swings weren’t nearly numerous enough to qualify for a diagnosis of cyclothymic disorder.

That leaves bipolar II disorder. But to qualify for that diagnosis, there must be at least one major depressive episode (bipolar II criterion A). On Iris’s second visit to the clinician, her depressive symptoms included feeling depressed most of the time, weight gain, hypersomnia, fatigue, and poor concentration (her “writer’s block”), which fulfill the criterion A requirements for major depressive episode. If her depression had not met the criteria for major depressive episode, her diagnosis would have been unspecified (or other specified) bipolar disorder. That’s the same conclusion you’d reach for a patient who has never had a depression and only hypomanic episodes—or, for Iris McMaster, if she’d stayed the course for her first office visit.

In coding bipolar II disorder, clinicians are asked to specify the most recent episode. Iris’s was a depression. Although bipolar II disorder provides no severity code for a hypomanic episode, we can rate her depression by the same criteria we’d use for any other major depressive episode. Though she had only the minimum number of symptoms needed for major depressive episode, her work had been seriously impaired. For that reason, moderate severity seems appropriate, and is mirrored in her GAF score of 60. If further interview revealed additional (or more serious) symptoms, I’d consider boosting her to severe level. These specifiers leave leeway for the clinician’s judgment.

During her depression Iris had a number of symptoms of an episode specifier: with atypical features. That is, her mood seemed to brighten when she was having lunch with her friend; she also gained weight, slept excessively, and had a sensation of heaviness (bricks) in her limbs. With a total of four of these symptoms (only three are required), at the time of the second interview her full diagnosis would read as follows:

ADDITIONAL MOOD DISORDERS

As we’ve discussed so far, many of the mood disorders seen in a mental health practice can be diagnosed by referring to manic, hypomanic, and major depressive episodes. These three mood episodes must be considered for any patient with mood symptoms. Next we’ll consider several other conditions that do not depend on these episodes for their definition.

F34.1 [300.4] Persistent Depressive Disorder (Dysthymia)

The condition discussed here goes by several names—dysthymic disorder, dysthymia, chronic depression, and now persistent depressive disorder. Whatever you call it (I’ll generally stick with dysthymia), these patients are indeed chronically depressed. 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.

In the course of a lifetime, perhaps 6% of adults have dysthymia, with women about twice as often affected as men. Although it can begin at any age, late onset is uncommon, and the classic case starts so quietly and so early in life that some patients regard their habitual low mood as, well, normal. In the distant past, clinicians regarded these patients as having depressive personality or depressive neurosis.

Dysthymic patients suffer quietly, and their disability can be subtle: they tend to put much of their energy into work, with less left over for social aspects of life. Because they don’t appear severely disabled, such individuals may go without treatment until their symptoms worsen into a more readily diagnosed major depressive episode. This is the fate of many, probably most, dysthymic patients. In 1993 this phenomenon was recounted in a book that made The New York Times best-seller list: Listening to Prozac. However, the astonishing response to medication that book reported is by no means limited to one drug.

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. The current criteria supply some specifiers to indicate the difference. Here’s what’s clear: Patients who have depression that goes on and on (whatever we choose to call it) tend to respond poorly to treatment, are highly likely to have relatives with either bipolar disorders or some form of depression, and continue to be ill at follow-up.

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.

The Fine Print

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

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)

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. Hasn’t met full criteria for major depressive episode for the past 2 years.

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.

Choose other specifiers from Table 3.3.

Noah Sanders

For Noah Sanders, life had never seemed much fun. He was 18 when he first noticed that most of the time he “just felt down.” Although he was bright and studied hard, throughout college he was often distracted by thoughts that he didn’t measure up to his classmates. He landed a job with a leading electronics firm, but turned down several promotions because he felt that he could not cope with added responsibility. It took dogged determination and long hours of work to compensate for this “inherent second-rateness.” The effort left him chronically tired. Even his marriage and the birth of his two daughters only relieved his gloom for a few weeks at a time, at best. His self-confidence was so low that, by common consent, his wife always made most of their family’s decisions.

“It’s the way I’ve always been. I am a professional pessimist,” Noah told his family doctor one day when he was in his early 30s. The doctor replied that he had a depressive personality.

For many years, that description seemed to fit. Then, when Noah was in his early 40s, his younger daughter left home for college; after this, he began to feel increasingly that life had passed him by. Over a period of several months, his depression deepened. He had worsened to the point that he now felt he had never really been depressed before. Even visits from his daughters, which had always cheered him up, failed to improve his outlook.

Usually a sound sleeper, Noah began awakening at about 4 A.M. and ruminating over his mistakes. His appetite fell off, and he lost weight. When for the third time in a week his wife found him weeping in their bedroom, he confessed that he had felt so guilty about his failures that he thought they’d all be better off without him. She decided that he needed treatment.

Noah was started on an antidepressant medication. Within 2 weeks, his mood had brightened and he was sleeping soundly; at 1 month, he had “never felt better” in his life. Whereas he had once avoided oral presentations at work, he began to look forward to them as “a chance to show what I could do.” His chronic fatigue faded, and he began jogging to use up some of his excess energy. In his spare time, he started his own small business to develop and promote some of his engineering innovations.

Noah remained on his medication thereafter. On the two or three occasions when he and his therapist tried to reduce it, he found himself relapsing into his old, depressive frame of mind. He continued to operate his small business as a sideline.

Evaluation of Noah Sanders

For most of his adult life, Noah’s mood symptoms were chronic, rather than acute or recurring. He was never without these symptoms for longer than a few weeks at a time (criterion C for dysthymia), and they were present most of the day, most days (A). They included general pessimism, poor self-image, and chronic tiredness, though only two symptoms are required by criterion B. His indecisiveness encouraged his wife to assume the role of family decision maker, which suggests social impairment (H). The way he felt was not different from his usual self; in fact, he said it was the way he had always been. (The extended duration is one of two main features that differentiate dysthymia from major depressive disorder. The other is that the required dysthymia symptoms are neither as plentiful nor as severe as for major depression.) Noah had had no manic or psychotic symptoms that might have us considering bipolar or psychotic disorders (E, F).

The differential diagnosis of dysthymia is essentially the same as that for major depressive disorder. Mood disorder due to another medical condition and substance-induced mood disorder must be ruled out (G). The remarkable chronicity and poor self-image invite speculation that Noah’s difficulties might be explained by a personality disorder, such as avoidant or dependent personality disorder. The vignette does not address all the criteria that would be necessary to make those diagnoses. However, an important diagnostic principle holds that the more treatable conditions should be diagnosed (and treated) first. If, despite relief of the mood disorder, Noah continued to be shy and awkward and to have a negative self-image, only then should we consider a personality diagnosis.

Now to the specifiers (Table 3.3). Though lacking psychotic symptoms, Noah had quite a number of depressive symptoms (including thoughts about death), which would suggest that he was severely ill. His dysthymia symptoms began when he was young (he first noticed them when he was just 18), so we’d say that his onset was early. Noah’s recent symptoms would also qualify for a major depressive episode, which had begun fairly recently and precipitated his evaluation; DSM-5 notes that a dysthymic patient can have symptoms that fulfill criteria for such an episode (D). We would therefore give him the specifier with intermittent major depressive episodes, with current episode. None of the course specifiers would apply to Noah’s dysthymia, but the following symptoms would meet the criteria for an episode specifier for the major depression—with melancholic features: He no longer reacted positively to pleasurable stimuli (being with his daughters); he described his mood as a definite change from normal; and he reported guilt feelings, early morning awakening, and loss of appetite.

Once treated, Noah seemed to undergo a personality change. His mood lightened and his behavior changed to the point that, by contrast, he seemed almost hypomanic. However, these symptoms don’t rise to the level required for a hypomanic episode; had that been the case, criterion E would exclude the diagnosis of dysthymia. (Also, remember that a hypomanic episode precipitated by treatment that does not extend past the physiological effects of treatment does not count toward a diagnosis of bipolar II disorder. It should not count against the diagnosis of dysthymia, either.) I thought his GAF score would be about 50 on first evaluation; his GAF would be a robust 90 at follow-up. In the summary, I’d note the possibility of avoidant personality traits.

My full diagnosis for Noah Sanders would be as follows:

F34.0 [301.13] Cyclothymic Disorder

Patients with cyclothymic disorder (CD) are chronically either elated or depressed, but for the first couple of years, they do not fulfill criteria for a manic, hypomanic, or major depressive episode. Note that there’s a phrase back there dripping with italics. I’ll explain in the sidebar below.

Cyclothymic disorder was at one time regarded as a personality disorder. This may have been partly due to the fact that it begins so gradually and lasts such a long time. Articles in the literature still refer to cyclothymic temperament, which may be a precursor to bipolar disorders.

The clinical appearance can be very variable. Some patients are nearly always dysphoric, occasionally shifting into hypomania for a day or so. Others can shift several times in a single day. Often the presentation is mixed.

Typically beginning gradually in adolescence or young adulthood, CD affects under 1% of the general population. However, clinicians diagnose it even less often than you’d expect. The sex distribution is about equal, though women are more likely to come for treatment. Not surprisingly, patients usually only come to clinical attention when they are depressed. Once begun, it tends toward chronicity.

What if your cyclothymic patient later develops a manic, hypomanic, or major depressive episode? In that case, you’ll have to change the diagnosis to something different. Once a major mood episode rears its head, that patient can never revert to CD. If the new episode is major depressive, then you’ll probably fall back on an unspecified (or other specified) bipolar disorder, inasmuch as, by definition, the “up” periods of CD will not qualify as a hypomanic episode. Note that this is a change from DSM-IV, which allowed a diagnosis of a bipolar disorder along with CD.

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.

The Fine Print

The D’s: • 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)

Coding Notes

Specify if: With anxious distress.

Honey Bare

“I’m a yo-yo!”

Without her feathers and sequins, Honey Bare looked anything but provocative. She had begun life as Melissa Schwartz, but she loved using her stage name. The stage in question was Hoofer’s, one of the bump-and-grind joints that thrived near the waterfront. The billboard proclaimed that it was “Only a Heartthrob Away” from the Navy recruiting station. Since she’d dropped out of college 4 years earlier, Honey had been a front-liner in the four-girl show at Hoofer’s. Every afternoon on her way to work she passed right by the mental health clinic, but this was her first visit inside.

“In our current gig, I play the Statue of Liberty. I receive the tired, the poor, and the huddled masses. Then I take off my robes.”

“Is that a problem?” the interviewer wanted to know.

Most of the time, it wasn’t. Honey liked her little corner of show biz. When the fleet was in, she played to thunderous applause. “In fact, I enjoy just about everything I do. I don’t drink much, and I never do drugs, but I go to parties. I sing in our church choir, go to movies—I enjoy art films quite a bit.” When she felt well, she slept little, talked a lot, started a hundred projects, and even finished some of them. “I’m really a happy person—when I’m feeling up.”

But every couple of months, there’d be a week or two when Honey didn’t enjoy much of anything. She’d paste a smile on her face and go to work, but when the curtain rang down, the smile came off with her makeup. She was never suicidal, and her sleep and appetite didn’t suffer; her energy and concentration were normal. But it was as if all the fizz had gone out of her ginger ale. She could see no obvious cause for her mood swings, which had been going on for years. She could count on the fingers of both hands the number of weeks she had been “just normal.”

Lately, Honey had acquired a boyfriend—a chief petty officer who wanted to marry her. He said he loved her because she was so vivacious and enthusiastic, but he had only seen her when she was bubbly. Always before, when she was depressed, he had been out to sea. Now he had written that he was being transferred to shore duty, and she feared it would be the end of their relationship. As she said it, two large tears trickled through the mascara and down her cheeks.

Four months and several visits later, Honey was back, wearing a smile. The lithium carbonate, she reported, seemed to be working well. The peaks and valleys of her moods had smoothed out to rolling hills. She was still playing the Statue of Liberty down at Hoofer’s.

“My sailor’s been back for nearly 3 months,” she said, “and he’s still carrying the torch for me.”

As far back as the mid-19th century, Karl Kahlbaum—the German psychiatrist who first described catatonia—noted that some people experience frequent alterations between highs and lows so mild as not to require any treatment. His observations were confirmed and extended by his student and colleague, Ewald Hecker (who was best known for his description of hebephrenic schizophrenia).

But by the mid-20th century, the first DSM described cyclothymia as a cardinal personality type (along with schizoid, paranoid, and inadequate personalities). The description actually sounds pretty wonderful: “an extratensive and outgoing adjustment to life situations, an apparent personal warmth, friendliness and superficial generosity, an emotional reaching out to the environment, and a ready enthusiasm for competition.” (I’ll leave the looking-up of extratensive as an extra-credit exercise.) Anyway, thus was born cyclothymia as a temperament or personality style.

DSM-II kept cyclothymic personality with the other personality disorders, but in 1980 it was moved to the mood disorders and rechristened with its current name. However, its relationship to other mood disorders is fraught; experts argue about it even today. Many hold that it can be prodromal to a more severe bipolar disorder. Some point out the similarities between cyclothymia and borderline personality disorder (labile, irritable moods leading to interpersonal conflict), even suggesting that the latter disorder belongs on the bipolar spectrum—a speculation extreme enough to invite resistance.

All of this suggests that we still have work to do in determining cyclothymic disorder’s exact place in the diagnostic firmament. Though the DSM-5 criteria are a step along the road to differentiation of this venerable diagnosis, they may not signify any real progress.

Evaluation of Honey Bare

The first and most obvious question is this: Had Honey ever fulfilled criteria for a manic, hypomanic, or major depressive episode (cyclothymic disorder criterion C)? When feeling down, she had no vegetative symptoms (problems with sleep or appetite) of major depressive episode. She had normal concentration, had never been suicidal, and did not complain of feeling worthless. At the other pole, she did indeed have symptoms similar to those of hypomania (talkative, slept less, was more active than at other times), but they weren’t even severe enough for hypomania. Honey’s “up” moods weren’t elevated (or irritable, or expansive) to an abnormal extent (hypomanic episode criterion A)—they were her normal functioning. Furthermore, she had experienced far more cycles than would be typical for bipolar II disorder. We can therefore rule out any other bipolar or major depressive diagnosis.

Honey testified that she was either up or down most of the time (we’re back to cyclothymia—criterion B). Because she was never psychotic, she could not qualify for a diagnosis such as schizoaffective disorder (D). She didn’t use drugs or alcohol, ruling out a substance-induced mood disorder (E). Again, bipolar I, bipolar II, and major depressive disorders are ruled out due to the lack of relevant episodes. (However, because they involve so many swings of mood, either bipolar I or II with rapid cycling can sometimes be confused with cyclothymic disorder.) Mood shifts, impulsivity, and interpersonal problems can of course be found aplenty in borderline personality disorder, but we’d never diagnose a personality disorder when a major mental diagnosis was available.

Symptoms that were present much of the time would qualify Honey for CD. She had many mood swings; only infrequently was her mood neither high nor low. The only specifier allowed with CD, with anxious distress, didn’t to me seem relevant to Honey’s symptoms. With a GAF score of 70 on admission and 90 at follow-up, her diagnosis would be simple:

N94.3 [625.4] Premenstrual Dysphoric Disorder

A long history of disagreement over the reality of premenstrual dysphoria caused it to languish in the appendices of earlier DSM editions. At last, enough research has been published to bring it forth from the shadows.

Premenstrual symptoms to one degree or another affect about 20% of women of reproductive age. The severe form, premenstrual dysphoric disorder (PDD), affects up to 7% of women, often beginning in the teenage years. Throughout their reproductive years, these symptoms appear for perhaps a week out of each menstrual cycle. These women complain of varying degrees of dysphoric mood, fatigue, and physical symptoms that include sensitivity of breasts, weight gain, and abdominal swelling. Differentiation from major depressive episode and dysthymia relies principally on timing and duration.

The consequences of PDD can be serious: Such a patient could experience mood symptoms during an accumulated 8 years of her reproductive life. Some patients may be unaware how markedly their anger and other negative moods affect those around them, and many suffer from severe depression; perhaps 15% attempt suicide. Yet the typical patient doesn’t receive treatment until she is 30, sometimes even later. Symptoms may be worse for older women, though menopause offers a natural endpoint (duration is sometimes extended by hormone replacement therapy). Overall, this condition ranks high among the seriously underdiagnosed mental disorders.

Risk factors for PDD 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.

Dating as far back as 1944—the term premenstrual tension dates at least to 1928—the premenstrual syndrome (PMS) has had a long and tempestuous life. It’s dismissed by many as pejorative, ridiculed by would-be comics, and disparaged even by some of those who practice gender politics. It should come as no surprise that it has been so ill received; as disorders go, PMS is remarkably vague and variously defined.

All told, PMS encompasses over a hundred possible symptoms, with no minimum number and no specific symptoms required; it’s all anecdotal. Here are just a few: fluid retention (the symptom most often reported), especially in breasts and abdomen; craving for sweet or salty foods; muscle aches/pains, fatigue, irritability, tension, acne, anxiety, constipation or diarrhea, and insomnia; a change in sex drive; and feeling sad or moody or out of control. Most women will occasionally have one or two of these symptoms around the time of their periods—these symptoms are so common that, individually, they may be considered physiological rather than pathological. This fact causes some people to blame all such symptoms on PMS (it hardly ever goes by its full, nonabbreviated name); all women are in effect tarred with the same brush, when it is of crucial importance to note the exact symptoms, their timing, and their intensity.

Again, the critical difference is the presence of mood symptoms in PDD.

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.

The Fine Print

The D’s: • 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)

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.

Amy Jernigan

“Look, I don’t need you to tell me what’s wrong. I know what’s wrong. I just need you to fix it.” One ankle crossed over the other, Amy Jernigan slouched in the consultation chair and gazed steadily at her clinician. “I brought a list of my symptoms, just so there won’t be any confusion.” She unfolded a half-sheet of embossed stationery.

“It always starts out 4 or 5 days before my period,” she recited. “I begin by feeling uptight, like I’m waiting to take an exam I haven’t studied for. Then, after a day or two, depression sets in and I just want to cry.” She looked up and smiled. “You won’t catch me doing that now—I’m always just fine after my period starts.”

Still in her early 20s, Amy had graduated from a college near her home in the Deep South. Now, while waiting for her novel to sell, she did research for a political blogger. With another glance at the paper, she continued. “But before, I’m depressed, cranky, lazy as a hound dog in August, and I don’t really give a shit about anything.”

Amy’s mother, an antifeminist who’d campaigned against the Equal Rights Amendment, had refused to validate Amy’s premenstrual symptoms, though she might have had them herself. Amy’s problems had begun in her early teens, almost from the time of her first period. “I’d be so pissed off, I’d drive away all my friends. Fortunately, I’m pretty outgoing, so they didn’t—don’t—stay lost for long. But reliably every month, my breasts get so sensitive they could read Braille. Then I know I’d better put a lock on my tongue, or the next week I’ll be buying beers for everyone I know.”

Amy tucked her list into her back pocket and sat up straight. “I hate being the feminist with PMS—I feel like a walking cliché.”

Discussion of Amy Jernigan

As Amy said, she didn’t need much discussion about what was wrong, though she didn’t have her terms quite right. Her list of symptoms—depression, irritability, and tension (criterion B) and breast tenderness, lethargy, and loss of interest (C)—exceeds the requirement for a total of five or more. Amy herself indicated just how debilitating she considered the symptoms to be (D). The recurrence, the timing, and the absence of symptoms at times other than before her menses (A) complete a pretty airtight case. The duration of her low moods was too brief for either a major depressive episode or dysthymia (E). Of course, the usual investigation must be made to rule out any lingering thoughts that her symptoms could be due to substance use or another medical condition (E). I should note that, in the absence of a couple of months of prospective symptom recording, Amy’s clinician needs to be extra careful to rule out major depressive disorder. It is awfully easy to ignore depressive symptoms that occur at other times of the month.

Amy’s clinician would have to assess her mood through two subsequent periods to comply with criterion F. When she was ill, her GAF score would be 60, and her diagnosis should be as follows:

The demand for prospective data before a definitive diagnosis can be made is unique in DSM-5, and has never been required in a prior edition of the DSM. The rationale is to ensure that the diagnosis is made with the best data possible; the fact that such a step is not required for more diagnoses may be a nod to the realities of clinical practice. Even so, we may have just experienced the first breeze of a gathering storm.

F34.8 [296.99] Disruptive Mood Dysregulation Disorder

New in DSM-5, disruptive mood dysregulation disorder (DMDD) showcases extremes of childhood. Most kids fight among themselves, but DMDD broadens the scope and intensity of battle. Minor provocations (insufficient cheese in a sandwich, a favorite shirt in the wash) can provoke these children to fly completely off the handle. In a burst of temper, they may threaten or bully siblings (and parents). Some may refuse to comply with chores, homework, or even basic hygiene. These outbursts occur every couple of days on average, and between them, the child’s mood is persistently negative—depressed, angry, or irritable.

Their behavior places these children at enormous social, educational, and emotional disadvantage. Low assessments of functioning reflect the trouble they have interacting with peers, teachers, and relatives. They require constant attention from parents, and if they go to school at all, sometimes they need minders to ensure their own safety and that of others. Some suffer such intense rage that those about them actually fear for their lives. Even relatively mild symptoms may cause children to forgo many normal childhood experiences, such as play dates and party invitations. In one sample, a third had been hospitalized.

Perhaps as many as 80% of children with DMDD will also meet criteria for oppositional defiant disorder, in which case you would only diagnose DMDD. The diagnosis is more common in boys than in girls, placing it at odds with most other mood disorders, though right in line with most other childhood disorders. Although the official DSM-5 criteria remind us not to make the diagnosis prior to age 6, limited studies find that it is most common in preschool children. And it needs to be discriminated from teenage rebellion—the teens are a transitional period where mood symptoms are common.

The question has been asked: Why was DMDD not included in the same chapter with the disruptive, impulse-control, and conduct disorders? Of course, 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.

Partly because this diagnosis is intended for children, but mainly because I’m really worried about the validity of a newly concocted, poorly studied formulation (see the sidebar below), I’ll not provide a vignette or further discussion at this time. At the same time, I’m really, reallyworried about all those kids who are being lumbered with a diagnosis of bipolar disorder, with attendant drug treatment.

How many disorders can you name that originated in an uncomfortable bulge in the number of patients being diagnosed with something else? I can think of exactly one, and here is how it came about.

Beginning in the mid-1990s, a few prominent American psychiatrists sufficiently relaxed the criteria for bipolar disorder to allow that diagnosis in children whose irritability was chronic, not episodic. Subsequently, the number of childhood bipolar diagnoses ballooned. Many other experts howled at what they perceived to be a subversion of the bipolar criteria; thus were drawn the battle lines for diagnostic war.

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

The epic internecine battle among American mental health professionals has been chronicled in a 2008 Frontline program (“The Bipolar Child”) on PBS and in a New York Times Magazine article by Jennifer Egan (“The Bipolar Puzzle,” September 12, 2008). The dispute continues; meanwhile, the DMDD category was crafted to capture more accurately the pathology of severely irritable children. The DSM-5 committee struggled to differentiate the two conditions, and I suspect that the struggles have only just begun.

Essential Features of Disruptive Mood Dysregulation Disorder

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.

The Fine Print

Delve into the D’s: • 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)

INDUCED MOOD DISORDERS

Substance/Medication-Induced Mood Disorders

Substance use is an especially common cause of mood disorder. Intoxication with cocaine or amphetamines can precipitate manic symptoms, and depression can result from withdrawal from cocaine, amphetamines, alcohol, or barbiturates. Note that for the diagnosis to be tenable, it must develop in close proximity to an episode of intoxication or withdrawal from the substance, which must in turn be capable of causing the symptoms.

Obviously, depression can occur with the misuse of alcohol and street drugs. (As DSM-5 notes, 40% or so of individuals with alcohol use disorder have depressive episodes, of which perhaps half are alcohol-induced, non-independent events.) However, even health care professionals can fail to recognize mood disorders caused by medications. That’s why the case of Erin Finn below is a cautionary tale, probably encountered every working day in clinicians’ offices around the world.

Essential Features of Substance/Medication-Induced Depressive Disorder

The use of some substance appears to have caused a patient to experience marked, persistent depressed mood or loss of interest in usual activities.

The Fine Print

For tips on identifying substance-related causation, see sidebar.

The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (physical disorders, other depressive disorders, “ordinary” substance intoxication or withdrawal, delirium)

Coding Notes

Specify if:

With onset during {intoxication}{withdrawal}. This gets tacked on at the end of your string of words.

With onset after medication use. You can use this in addition to other specifiers. See sidebar.

Code depending on whether there is evidence that supports a mild or moderate/severe substance use disorder (see Tables 15.2 and 15.3 in Chapter 15).

Essential Features of Substance/Medication-Induced Bipolar and Related Disorder

The use of some substance appears to have caused a mood that is euphoric or irritable.

The Fine Print

For tips on identifying substance-related causation, see sidebar.

The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (physical disorders, other bipolar disorders, schizoaffective disorder, “ordinary” substance intoxication or withdrawal, delirium)

Coding Notes

With onset during {intoxication}{withdrawal}. This gets tacked on at the end of your string of words.

With onset after medication use. You can use this in addition to other specifiers. See sidebar.

Code depending on whether there is evidence that supports a mild or moderate/severe substance use disorder (see Tables 15.2 and 15.3 in Chapter 15).

Erin Finn

Erin Finn came to the clinic straight from her job as media specialist at a political campaign. She’d taken part in her state’s screening program for hepatitis C, which targeted people in her age group—reared before routine testing of the blood supply had reduced the incidence of the disease. Her test had come back positive. When the RNA polymerase test revealed a viral load, she’d agreed to a trial of interferon. “I sometimes feel tired, but I’ve had no other symptoms,” she’d told her doctor.

Though solidly middle-class and conservatively dressed, Erin had actually had a number of possible exposures to hepatitis C. The most likely was a years-ago blood transfusion, but she’d also “had a wild-ish youth, experimented with injectable drugs a few times, even got a tattoo. It’s more or less discreet—the tattoo, I mean.”

Within a few days of starting the medication, she’d begun to complain of feeling depressed, first mildly, then increasing day by day. “It felt worse than that day last year when we thought we’d lost in the primary election,” she told the interviewer. “It’s been a horrible combination of sleeping poorly at night and never completely waking up during the day. And feeling draggy, and tired, and . . . ” She groped for words while fiddling with the two campaign buttons pinned to her coat.

Originally hired to do data entry, Erin had been promoted to write campaign materials for brochures and television. But because she was depressed most of the day, her inability to concentrate had resulted in mistakes. “I’m a crap worker,” she said, “always making simple mistakes in grammar and spelling. It’ll be my fault if we lose in November.”

After a moment, she added, “But I’m not suicidal, I’m not that dumb. Or desperate. But some days, I just wish I was dead.” She thought for a moment. “Were dead!” she corrected herself. “And my boyfriend tells me I’m useless in bed. Along with everything else, I just don’t seem to care about that any more, either.”

Erin subsequently stopped the interferon, and her mood and other symptoms gradually returned to normal. “So the doctor thought I ought to try the interferon again, as a sort of challenge. At first, I said that was a total nonstarter! But then I got to worrying some more about cirrhosis, and thought I’d give it another shot. So to speak.”

She shrugged as she rolled up her sleeve. “I guess hepatitis treatment has a lot in common with politics—neither of them’s bean-bag.”

Evaluation of Erin Finn

Erin’s symptoms would rate her a diagnosis of (relatively mild) major depressive episode, even leaving out the fatigue (which we won’t count because it antedated her use of interferon). Even without all those depressive symptoms, the mere fact of having such a pronounced low mood would fulfill the requirement for medication-induced depressive disorder criterion A. The timing was right (B1), and interferon is well known to produce depressive symptoms in a sizeable number of patients (though more often in those who have had previous mood episodes—B2). And, although it was hardly a controlled experiment, her depressive symptoms did clear up right away, once she stopped the interferon. DSM-5 doesn’t specify a challenge test (sometimes such a test is inadvisable), but a return of Erin’s depressive symptoms after she resumed the medication would forge the final cause-and-effect link.

OK, so we should consider other possible causes of her depression (criteria C and D). I’ll leave that as an exercise for the reader. As for criterion E (distress and disability), res ipsa loquitur. When we turn to Table 15.2 in Chapter 15 for ICD-10 coding, her substance was “Other” (F19), and she had obviously used it only as prescribed, so there was no use disorder. Cross-indexing with the mood disorder column yields F19.94. The ICD-9 code comes from Table 15.3. I would give her GAF score as 55 on admission, 90 at discharge.

Mood Disorders Due to Another Medical Condition

Many medical conditions can cause depressive or bipolar symptoms, and it is vital always to consider physical etiologies when evaluating a mood disorder. This is not only because they are treatable; with today’s therapeutic options, most mood disorders are highly treatable. It is because some of the general medical conditions, if left inadequately treated too long, themselves have serious consequences—including death. And there are not a few that can cause manic symptoms. I’ve mentioned some of these in the “Physical Disorders That Affect Mental Diagnosis” table in the Appendix, though that table is by no means comprehensive.

Note this really important requirement: The medical condition has to have been the direct, physiological cause of the bipolar or depressive symptoms. Psychological causation (for instance, the patient feels understandably terrible upon being told “it’s cancer”) doesn’t count, except as the possible precipitant for an adjustment disorder.

The vignette of Lisa Voorhees below illustrates the importance of keeping in mind that medical conditions can cause mood disorders.

Essential Features of Depressive Disorder Due to Another Medical Condition

A physical medical condition appears to have caused a patient to experience a markedly depressed mood or loss of interest or pleasure in most activities.

The Fine Print

For pointers on deciding when a physical condition may have caused a mental disorder, see sidebar.

The D’s: • Duration (none stated, though it would not be fleeting) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use disorders, other depressive disorders, delirium)

Coding Notes

Specify:

F06.31 [293.83] With depressive features. You cannot identify full symptomatic criteria for a major depressive episode.

F06.32 [293.83] With major depressive-like episode. You can.

F06.34 [293.83] With mixed features. Manic or hypomanic symptoms are evident but not predominant over the depressive symptoms.

It is only with DSM-5 that criteria have been written specifically differentiating medically induced bipolar from medically induced depressive disorders. What if you can’t tell? Some mood disorders, in their early stages, may be too indistinct to call. You might then be reduced to diagnosing mood disorder due to a medical condition (F06.30) or substance-induced mood disorder (F19.94).

Essential Features of Bipolar and Related Disorder Due to Another Medical Condition

A physical medical condition appears to have caused a patient to experience both an elevated (or irritable) mood and an atypical increase in energy or activity, though full manic episode symptoms may not be present.

The Fine Print

For pointers on deciding when a physical condition may have caused a mental disorder, see sidebar.

The D’s: • Duration (none stated, though it would not be fleeting) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use disorders, other bipolar disorders, other mental disorders, delirium)

Coding Notes

Specify:

F06.33 [293.83] With manic- or hypomanic-like episode. You can identify full symptomatic criteria for mania or hypomania.

F06.33 [293.83] With manic features. Full mania or hypomania criteria are not met.

F06.34 [293.83] With mixed features. Depressive symptoms are evident but not predominant over the manic symptoms.

Lisa Voorhees

By the time she arrived at the mental health clinic, Lisa Voorhees had already seen three doctors. Each of them had thought that her problems were entirely mental. Although she had “been 39 for several years,” she was slender and smart, and she knew that she was attractive to men.

She intended to stay that way. Her job as personal secretary to the chairman of the department of English and literature at a large Midwestern university introduced her to a lot of eligible males. And that was where Lisa first noticed the problem that made her think she was losing her mind.

“It was this gorgeous assistant professor of Romance languages,” she told the interviewer. “He was always in and out of the office, and I’d done everything short of sexual harassment to get him to notice me. Then one day last spring, he asked me out to dinner and a show. And I turned him down! I just wasn’t interested. It was as if my sex drive had gone on sabbatical!”

For several weeks she continued to feel uninterested in men, and then one morning she “woke up next to some odious creep from the provost’s office” she’d been avoiding for months. She felt disgusted with herself, but they had sex again anyway, before she kicked him out.

For the next several months, Lisa’s sexual appetite would suddenly change every 2 or 3 weeks. Privately, she had begun to call it “The Turn of the Screw.” During her active phase, she felt airy and light, and could pound away on her computer 12 hours a day. But the rest of the time, nothing pleased her. She was depressed and grouchy at the office, slept badly (and alone), and joked that her keyboard and mouse were conspiring to make her feel clumsy.

Even Lisa’s wrists felt weak. She had bought a wrist rest to use when she was typing, and that helped for a while. But she could find neither splint nor tonic for the fluctuations of her sex drive. One doctor told her it was “the change” and prescribed estrogen; another diagnosed “manic–depression” and offered lithium. A third suggested pastoral counseling, but instead she had come to the clinic.

In frustration, Lisa arose from her chair and paced to the window and back.

“Wait a minute—do that again,” the interviewer ordered.

“Do what? All I did was walk across the room.”

“I know. How long have you had that limp?”

“I don’t know. Not long, I guess. What with the other problems, I hardly noticed. Does it matter?”

It proved to be the key. Three visits to a neurologist, some X-rays, and an MRI later, Lisa’s diagnosis was multiple sclerosis. The neurologist explained that multiple sclerosis sometimes caused mood swings; treatment for it was instituted, and Lisa was referred back to the mental health clinic for psychotherapy.

Evaluation of Lisa Voorhees

On paper, the various criteria sets make reasonably clear-cut the differences between mood disorders with “emotional” causes and those caused by general medical conditions or substance use. In practice, it isn’t always obvious.

Lisa’s mood symptoms alternated between periods of highs and lows. Although they lasted 2 weeks or longer, none of these extremes was severe enough to qualify as a manic, hypomanic, or major depressive episode. The depressed period was too brief for dysthymia; the whole episode had not lasted long enough for cyclothymic disorder; and there was no evidence of a substance-induced mood disorder.

Depressive (or bipolar) disorder due to another medical condition must fulfill two important criteria. The first is that symptoms must be directly produced by physiological mechanisms of the illness itself, not simply by an emotional reaction to having the illness. For example, patients with cancer of the head of the pancreas are known to have a special risk of depression, which doesn’t occur just as a reaction to the news or continuing stress of having a serious medical problem.

Several lines of evidence could bear on a causal relationship between a medical condition and mood symptoms. A connection may exist if the mood disorder is more severe than the general medical symptoms seem to warrant or than the psychological impact would be on most people. However, such a connection would not be presumed if the mood symptoms begin before the patient learns of the general medical condition. Similar mood symptoms developing upon the disclosure of a different medical problem would argue against a diagnosis of either bipolar or depressive disorder due to another medical condition. By contrast, arguing for a connection would be clinical features different from those usual for a primary mood disorder (such as atypical age of onset). None of these conditions obtained in the case of Lisa Voorhees.

A known pathological mechanism that can explain the development of the mood symptoms in physiological terms obviously argues strongly in favor of a causal relationship. Multiple sclerosis, affecting many areas of the brain, would appear to satisfy this criterion. A high percentage of patients with multiple sclerosis have reported mood swings. Periods of euphoria have also been reported in these patients; anxiety may be more common still.

Many other medical conditions can cause depression. Endocrine disorders are important causes: Hypothyroidism and hypoadrenocorticalism are associated with depressive symptoms, whereas hyperthyroidism and hyperadrenocorticalism are linked with manic or hypomanic symptoms. Infectious diseases can cause depressive symptoms (many otherwise normal people have noted lassitude and low mood when suffering from a bout of the flu; Lyme disease has been getting a lot of attention recently). Space-occupying lesions of the brain (tumors and abscesses) have also been associated with depressive symptoms, as have vitamin deficiencies. Finally, about one-third of patients with Alzheimer’s disease, Huntington’s disease, and stroke may develop serious depressive symptoms.

The second major criterion for a mood disorder due to another medical condition is that the mood symptoms must not occur only during the course of a delirium. Delirious patients can have difficulties with memory, concentration, lack of interest, episodes of tearfulness, and frank depression that closely resemble major depressive disorder. Lisa presented no evidence that suggested delirium.

As to the specifier, we could choose between with manic features and with mixed features (see Essential Features, above). At different times, Lisa had both extremes of mood; neither predominated, so I’d go with . . . well, see below, along with a GAF score of 70. The code and name of the general medical condition would be included, as follows, with the name of the medical condition:

MODIFIERS OF MOOD DIAGNOSES

Table 3.3 shows at a glance when and how to apply each of the modifiers of mood disorders covered below.

Severity and Remission

Severity Codes

Neither major depressive episode, manic episode, nor hypomanic episode is codable (stop me if you’ve heard this before). Instead, we use each as the basis for other diagnoses. However, they do have severity codes attached to them, and the same severity codes are used for major depressive and manic episodes. Use these codes for the current or most recent major depressive episode in major depressive, bipolar I, or bipolar II disorders, or the current or most recent manic episode in the two bipolar disorders. (Hypomanic episode is by definition relatively mild, so it gets no severity specifier.)

The basic severity codes for manic and major depressive episodes are these:

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.

Remission Codes

The majority of patients with bipolar disorders recover completely between episodes (and most of them will have subsequent episodes). Still, up to a third of patients with bipolar I do not recover completely. The figures for patients with major depressive disorder are not quite so grim. Following are two specifiers for current status of both these disorders, as well as bipolar II disorder and persistent depressive disorder (aka dysthymia).

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.

Specifiers That Describe the Most Recent Mood Episode

The episode specifiers describe features of the patient’s current or most recent episode of illness. No additional code number is assigned for these features; you just write out the verbiage. Again, Table 3.3 shows at a glance when you can use each of the following special qualifiers.

With Anxious Distress

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.

Essential Features of With Anxious Distress

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)

See Table 3.3 for application.

There’s something kind of funny here. We’ve been given a mood specifier that has its own severity scale, derived (as are manic and major depressive episodes) by counting symptoms. If there’s any other place in DSM-5 where it’s possible to have two separate severity ratings in the same diagnosis, I don’t recall it. (Other specifiers have several symptoms to count; for example, why don’t we also rate severity of with melancholic features?) Furthermore, it is at least theoretically possible for a patient to have mild depression with severe anxious distress. Of course, you can rate each part independently, but it could be confusing and it sounds a little silly. My approach would be to focus on the severity of the mood episode. The specifier will probably get along just fine on its own.

With Atypical Features

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.

Iris McMaster’s bipolar II disorder included atypical features.

Essential Features of With Atypical Features

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.

With Catatonia

The catatonia specifier, first mentioned in Chapter 2 in association with the psychotic disorders, 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. When you use it, you have to add a line of extra code after listing and coding the other mental disorder:

I’ve given an example in the case of Edward Clapham.

With Melancholic Features

The with melancholic features specifier refers to the classical “vegetative” symptoms of severe depression and a negative view of the world. Melancholic patients awaken too early in the morning, feeling worse than they do later in the day. They also have reduced appetite and lose weight. They take little pleasure in their usual activities (including sex) and are not cheered by the presence of people whose company they normally enjoy. This loss of pleasure is not merely relative, but total or nearly so. Brian Murphy is an example of such a patient; Noah Sanders is another.

Melancholic features are especially common among patients who first develop severe depression in midlife. This condition used to be called involutional melancholia, from the observation that it seemed to occur in patients who were in middle to old age (life’s so-called “involutional” period). However, it is now recognized that melancholic features can affect patients of any age; they are especially likely to occur in psychotic depressions. Depression with melancholia usually responds well to somatic treatments such as antidepressant medication and ECT. Contrast this picture with that given for with atypical features (see above).

Again, see Table 3.3 for details of when to apply this specifier.

Essential Features of With Melancholic Features

In the depths of a major depressive episode, the patient cannot find pleasure in accustomed activities or feels no better if something good happens (OK, could be both). Such a patient also experiences some of these: a mood more deeply depressed than what you’d expect during bereavement; diurnal variation of mood (more depressed in the morning); terminal insomnia (awakening at least 2 hours early); change in psychomotor activity (sometimes agitated, more often slowed down); marked loss of appetite or weight; and guilt feelings that are unwarranted or excessive. This form of depression is extremely severe and can border on psychosis.

Coding Notes

You can apply this specifier to a major depressive episode, wherever it occurs: major depressive disorder (single episode or recurrent), bipolar I or II disorder, or persistent depressive disorder. See Table 3.3.

With Mixed Features

In 1921, Emil Kraepelin first described mixed forms of mania and depression. DSM-IV and its predecessors included a mixed episode among the mood disorders. Now that it’s been retired, DSM-5 offers a with mixed features specifier to use with patients who within the same time frame have symptoms of depression and mania (or hypomania). The features of the two opposite poles occur more or less at the same time, though some patients experience the gradual introduction (then fading away) of, say, depression into a manic episode.

However, researchers are only just ascertaining the degree to which such a patient differs from someone with “pure” episodic mania or depression. Patients who have mixed features appear to have more total episodes and more depressive episodes, and remain ill longer. They may tend to have more comorbid mental illness and greater suicide risk. Their work is more likely to be impaired. Patients with major depressive disorder who have mixed features are especially likely to develop a bipolar disorder in the future.

Despite this attention, we’ll probably continue to use the with mixed features specifier less often than could be justified. Several studies suggest that a third or more of bipolar patients have at least one episode with mixed symptoms; some reports suggest that mixed mood states are more frequent in women than in men.

You can apply this specifier to episodes of major depression, mania, and hypomania (see Table 3.3). Because of the greater impairment and overall severity of mania symptoms, if you have a patient who meets full criteria for both mania and major depression, you should probably go with the diagnosis of bipolar I disorder with mixed features, rather than major depressive disorder with mixed features. Winona Fisk had bipolar I disorder with mixed features.

The criteria for with mixed features omit some of the mood symptoms found in manic and major depressive episodes. That’s because they might conceivably belongon both lists, and hence do not indicate a mixed presentation. These symptoms include certain problems with sleep, appetite/weight, irritability, agitation, and concentration. Note, by the way, that the patient must meet full criteria for major depressive, manic, or hypomanic episode.

The criteria are silent as to how long each day (or, actually, the majority of days) the mixed features must be present, and I don’t know of any data that would help us understand this question better. Right now, even a few minutes a day, repeated day after day, would seem enough to earn this specifier. Only additional research is going to help us understand whether that’s a sensible time frame—or too short, or too long. Right now, that picture is decidedly mixed.

Essential Features of With Mixed Features

Here, there are two ways to go.

A patient with a manic or hypomanic episode also has some noticeable symptoms of depression most days: depressed mood, low interest or pleasure in activities, an activity level that is speeded up or slowed down, feeling tired, feeling worthless or guilty, and repeated thoughts about death or suicide. (See Coding Note.)

A patient with major depressive episode also has some noticeable symptoms of mania most days: heightened mood, grandiosity, increased talkativeness, flight of ideas, increased energy level, poor judgment (such as excessive spending, sexual adventures, imprudent financial speculations), and reduced need for sleep.

The Fine Print

The D: • Differential diagnosis (physical disorders, substance use disorders)

Coding Note

The impairment and severity of full-blown mania suggest that patients who simultaneously meet full episode criteria for both manic and depressive episodes should be recorded as having manic episode, with mixed features.

With Peripartum Onset

Over half of all women have “baby blues” after giving birth: They may feel sad and anxious, cry, complain of poor attention, and have trouble sleeping. This lasts a week or two and is usually of little consequence. But about 10% of women have enough symptoms to be diagnosed as having a depressive disorder; these people often have a personal history of mental disorder. An episode of hypomania may be especially likely after childbirth. Only about 2 out of 1,000 new mothers actually become psychotic.

The with peripartum onset specifier has the briefest Essential Features in this book. Though Elisabeth Jacks had a manic episode after giving birth, a major depressive episode would be much the more common response. With peripartum onset can apply to bipolar I and bipolar II disorders, to either type of major depressive disorder, or to brief psychotic disorder (see Table 3.3 for all applications except to brief psychotic disorder).

Essential Features of With Peripartum Onset

A female patient’s mood disorder starts during pregnancy or within a month of giving birth.

Coding Notes

See Table 3.3 for application.

In the mood disorders, it’s called with peripartum onset. However, when it occurs with brief psychotic disorder, it’s called with postpartum onset, even though it’s described there as occurring “during pregnancy or within 4 weeks postpartum.” This is just one more little glitch that will probably get sorted out, by and by. Use it either way in any context, and you’re still likely to be understood.

With Psychotic Features

Irrespective of the severity rating, some patients with manic or major depressive episodes will have delusions or hallucinations. (Of course, most of these patients you will have rated as being severely ill, but it is at least theoretically possible that someone could have just a few symptoms—including psychosis—that for whatever reason haven’t hugely inconvenienced them.) Around half of patients with bipolar I disorder will have psychotic symptoms; far fewer patients with major depressive disorder will be psychotic.

Psychotic symptoms may be mood-congruent or mood-incongruent. Specify, if possible:

With mood-congruent psychotic features. The content of the patient’s delusions or hallucinations is completely in accord with the usual themes of the relevant mood episode. For major depression, these include death, disease, guilt, delusions of nihilism (nothingness), personal inadequacy, or punishment that is deserved; for mania, they include exaggerated ideas of identity, knowledge, power, self-worth, or relationship to God or someone else famous.

With mood-incongruent psychotic features. The content of the patient’s delusions or hallucinations is not in accord with the usual themes of the mood episode. For both mania and major depression, these include delusions of persecution, control, thought broadcasting, and thought insertion.

Essential Features of With Psychotic Features

The patient has hallucinations or delusions.

Coding Notes

Specify, if possible:

With mood-congruent psychotic features. The psychotic symptoms match what you’d expect from the basic manic or depressive mood (see above).

With mood-incongruent psychotic features. They don’t match.

Specifiers That Describe Episode Patterns

Two specifiers describe the frequency or timing of mood episodes. Their appropriate uses are summarized below in Table 3.3, as are those for the other types of specifiers.

With Rapid Cycling

Typically, the bipolar disorders follow a more or less indolent course: a number of months (perhaps 3–9) of depression, followed by somewhat fewer months of mania or hypomania. Other than their number, the individual episodes meet full criteria for major depressive, manic, or hypomanic episodes. As patients age, the entire cycle tends to speed up, but most patients have no more than one up-and-down cycle per year, even after five or more complete cycles. Some patients, however, especially women, cycle much more rapidly than this: They may go from mania to depression to mania again within a few weeks. (Their symptoms meet full mood episode requirements—that’s how they differ from cyclothymic disorder.)

Recent research suggests that patients who cycle rapidly are more likely to originate from higher socioeconomic classes; in addition, a past history of rapid cycling predicts that this pattern will continue in the future. Rapid cyclers may be more difficult to manage with standard maintenance regimens than other patients, and they may have a poorer overall prognosis. With rapid cycling can apply to bipolar I and bipolar II disorders.

Essential Features of With Rapid Cycling

A patient has four or more episodes per year of major depression, mania, or hypomania.

Coding Notes

To count as a separate episode, an episode must be marked by remission (part or full) for 2+ months or by a change in polarity (such as from manic to major depressive episode).

With Seasonal Pattern

Here is yet another specifier for mood disorders that has only been recognized in the last few decades. In the usual pattern, depressive symptoms (these are often also atypical) appear during fall or winter months and remit in the spring and summer. Patients with winter depression may report other difficulties, such as pain disorder symptoms or a craving for carbohydrates, during their depressed phase. Winter depressions occur more commonly in polar climates, especially in the far North, and younger people may be more susceptible. With seasonal pattern can apply to bipolar I and bipolar II disorders and to major depressive disorder, recurrent type. There may also be seasonality to manic symptoms, although this is far less well established. (Bipolar I patients may experience the seasonal pattern with one type of episode, not with the other.)

Sal Camozzi’s bipolar II disorder included a seasonal pattern. His history is presented in Chapter 11.

Essential Features of With Seasonal Pattern

The patient’s mood episodes repeatedly begin (and end) at about the same times of year. The seasonal episodes have been the only episodes for at least the past 2 years. Lifelong, seasonal episodes materially outnumber nonseasonal ones

The Fine Print

Disregard examples where there is a clear seasonal cause, such as being laid off every summer.

PUTTING IT ALL TOGETHER: CODING AND LABELING THE MOOD DISORDERS

Coding and labeling the mood disorders, especially major depressive disorder and bipolar I disorder, have always been complex undertakings—and DSM-5 and ICD-10 have further complicated them. Table 3.2 lays out the possible codes for bipolar I and major depressive disorders. A footnote to this table give two examples of how to label particular presentations of these disorders.

In addition to the three bipolar types listed in Table 3.2, there is also the possibility of bipolar I, unspecified type. That’s mainly intended for the folks in the record room when we neglect to indicate the polarity of the most recent episode. We clinicians should ordinarily have little occasion to use this code. Because the episode type is unknown, no episode specifiers can apply.

Table 3.3 summarizes all the descriptors and specifiers that can apply to mood disorders, and indicates with which disorders each modifier can be used.

DSM-5 doesn’t say that the depression of bipolar II disorder can have atypical, melancholic, or psychotic features. But neither does it say that it can’t. I say that if you encounter a patient with bipolar II disorder who has any of those features, step right up and declare it. It’ll do you a world of good.

OTHER SPECIFIED AND UNSPECIFIED MOOD DISORDERS

F31.89 [296.89] Other Specified Bipolar and Related Disorder

Use other specified bipolar and related disorder when you want to write down the specific reason your patient cannot receive a more definite bipolar diagnosis. To prevent overuse and “medicalization” of the normal ebb and flow of mood, the patient must have symptoms that don’t qualify for a more specific bipolar disorder diagnosis and that cause distress or interfere with the patient’s normal functioning. DSM-5 gives a number of examples:

Short-duration hypomanic episodes (2–3 days) and major depressive episodes. Such a patient will have had at least one fully qualified major depressive episode, plus at least one episode of hypomania too brief (2–3 days) to justify a diagnosis of bipolar II disorder. Because the depression and hypomania don’t occur together, a with mixed features designation wouldn’t be appropriate.

Hypomanic episodes with insufficient symptoms and major depressive episodes. Such a patient will have had least one major depressive episode but no actual manic or hypomanic episodes, though there will have been at least one episode of subthreshold hypomania. That is, the high phase is long enough (4 days or more) but is a symptom or two shy of the number required for a hypomanic episode (elevated mood plus one or two of the other symptoms of a hypomanic episode, or irritable mood plus two or three of the other symptoms of hypomania). The hypomanic and major depressive symptoms don’t overlap, so you can’t call it major depressive episode with mixed features.

Hypomanic episode without prior major depressive episode. Here you’d classify (no surprise) someone who has had an episode of hypomania but who hasn’t ever fully met criteria for a major depressive episode or a manic episode.

Short-duration cyclothymia. In a period less than 2 years (less than 12 months for a child or adolescent), such a patient will have had multiple episodes of both hypomanic symptoms and depressive symptoms, all of which will have been either too brief or have too few symptoms to qualify for a major depressive or hypomanic episode. Of course, there will be no manias and no symptoms of psychosis. Patients with short-duration cyclothymia will have symptoms for a majority of days and will have no symptom-free periods longer than 2 months.

Note that DSM-5 cautions us not to use just other specified bipolar disorder or other specified depressive disorder as the actual diagnosis. Rather, we are also supposed to state, in full, one of the many (often cumbersome) titles given in the bipolar list just above and the depressive list below. One thing is certain: Regardless of which of the several discrete terms we choose, there is just one code number for each of these two categories of uncertainty.

F31.9 [296.80] Unspecified Bipolar and Related Disorder

And here you’d include patients for whom you don’t care to indicate the reason you aren’t diagnosing a well-defined bipolar condition.

F32.8 [311] Other Specified Depressive Disorder

Use other specified depressive disorder in the same way as described above for other specified bipolar and related disorder. DSM-5 provides the following examples of other specified depressive disorder:

Recurrent brief depression. Every month for 12+ months, lasting from 2 to 13 days at a time, these patients have low mood plus at least four other symptoms of depression that aren’t associated with menstruation. The patients have never fulfilled criteria for another mood disorder, and they’ve not been psychotic.

Short-duration depressive episode. These patients would meet criteria for major depressive episode except for duration—their episodes last 4–13 days. Here’s the full run-down: depressed mood; at least four other major depressive symptoms; clinically significant distress or impairment; have never met criteria for other mood disorders; not currently psychotic; and don’t meet criteria for other conditions.

Depressive episode with insufficient symptoms. These patients would meet criteria (duration, distress) for major depression, except that they have too few symptoms. They don’t have another psychotic or mood disorder.

F32.9 [311] Unspecified Depressive Disorder

As for unspecified bipolar and related disorder, when you don’t care to indicate the reason for a more secure diagnosis, you can use the unspecified depressive disorder category. The advantage: mood disorders “of uncertain etiology” have been used so often in the past as to undermine their value.

Whenever we clinicians encounter a patient with schizophrenia and postpsychotic depressive disorder, or one with a major depressive episode superimposed on a psychosis, we should think extra carefully about the diagnosis. Likewise, the occurrence of a manic episode in a patient who was formerly diagnosed as psychotic should cause us to wonder whether the original diagnosis was correct. In both cases, some of these patients may actually have bipolar I disorder, and not schizophrenia or another psychotic disorder at all. This would appear to be an ongoing problem, regardless of which edition of the DSM we are using.

*I suppose it’s possible that a patient with bipolar II disorder might end up hospitalized without really needing it. In that case, I’d go with the predominant symptoms and call it bipolar II.