DSM%20Mood%20Disorders%20reading

DSM%20Mood%20Disorders%20reading - DIAGNOSTIC AND...

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Unformatted text preview: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS FOURTH EDITION Published by the American Psychiatric Association Arlington, VA Mood Disorders _I he Mood Disorders section includes disorders that have .i dismrbance in mood as the predominant leature. The section i - divided into three parts. The first part de« scribes mood episodes {Maiior Depressive Episode. Manic Episode, Mixed Epistxie, and Hypornanie Episode} that have been ini‘luded separate!)r at the begitutltlg of this Section for convenience in diagnosing the various Mood Disorders. These episodes do not have their own diagnostic codes and cannot be diagnosed as separate entities; however, they serve as the building blocks for the disorder diagnoses. The second part describes the Mood Disorders fog... \rlaaor Depressive Disorder, Dysthymie Dis- order, Bipoiari Disorder]. The. criteria sets for most of the Mood Disorders require the presence or absence of the mood episodes described in the First part or the section. The third part includes the specifiers that describe either the most recent mood epi- sode or the course of recurrent episodes. The Mood Disorders are divided into the Depressive Disorders ["unipolar depres' simi"). ihc‘ Bipniar Disorders. and two disorders based on etiologvu-Mood Disorder Due to a General Medical Condition and Substnnrevlnduced Mood Disorder. The pressive Disorders {i.e., Major Depressive Disorder, Dvsihymlc Disorder, and De- pmsswe Disorder Not Otherwise Specified] are distinguished iron: the Bipolar Disorders by the tart that there is no history of ever having had a Manic, Mixed. or Hypomunic Episode. The Bipolar Disorders (5e, Bipolar I Disorder. Bipolar Ii Dis- order, Cyclothyni ic Disorder, and Bipolar Disorder Not Otherwise Specified) involve the. presence (or historyi of Manic Episodes, Mixed Episodes, or Ilypomanic Epi- sodes, usually accompanied by the presence {or history] of Major Depressive Epi- sodas. Major Depressive Disorder is characterized by one or more Major Depressive Ep- isodes (in, at leasl 2 weeks of depressed mood or loss of interest accompanied by at least tour additional symptoms oi depression}. Dysthvmic Disorder is characterized by at least 2 years of depressed mood [or more days than notr accompanied by additional depressive symptoms that do not meet criteria for a Major Depressive Episode. Depressive Disorder Not Otherwise Specified is included for coding disorders with depressive features that do not meet criteria for Major Depressive Disorder. Dysthymie Disorder, Adjustment Disorder With Depressed Mood, or Adjustment Disorder Witt: Mixed Anxiety and Depressed Mmd [or depressive symptoms about whii'h there. is inadequate or contradictory information). Bipuiar I Disorder is characterized by one or more Manic or Mixed Episodes. usu- alig' accompanied by Major Depressive Episodes. Bipolar {I Disorder is characterized hv one or more Major Depressive Episodes ac- companiod by at least one I-vaomanic i3 isode. ' d Mood Disorders Mood DISOI' ers Cyclmhymir Disorder is characterized by at least 2 years of numerous periods of hypomanic symptoms that do not meet criteria For a Manic Episode periods of depressive symptoms that do not meet criteria for Episode. Bipolar Disorder Not Olherwise Specified is included bipolar feamres that do not meet criteria fined in this section (or bipolar sy dictory information}. Mood Disorder Due to a General Medical Cond ineiil and persistent disturbance in mood that is iu consequence of a general medical condition. Substance—Induced Mood Disorder ls chara tent disturbance in mood that is judged to be a drug of abuse, a medication. another poser-c. Mood Disorder Not Otherwise S and numerous in Major Depressive for coding disorders with for any of the specific Bipolar Disorders de. mptoms about which there is inadequate or contra. itiun is characterized by a prom. dgod to be a direct physiological clerizcd by a prominent and persig‘ a direct physiological consequence of somatic treatment for depression, or toxin ex. pacified is included for coding disorders with mood symptoms that do not meet the criteria for any specific Mood Disorder and in which it is difficult to choose between Depressive Disorder Not Otherwise Specified and Bipolar Disorder Not Otherwise Specified (e.g._. acute agitation]. The specifiers described in the third part of the section are provided to increase di— agnostic specificity, create more homogeneous subgroups, assist in treatment selec- tion, and improve the prediction of prognosis. Some of the specifiers describe the clinic-at status of the current {or most recent] mood episode tie, Severityll’sychoticl Remission Spacifiers}, whereas others describe features of the current episode for most recent episode it' 1119 episode is currently in partial or full remissith {i.e., Chron- ic. With Calatonic Features, With Melanchulic Features, With Atypical Features, With Postpartum Onset]. Table i (p. 41]) indicates which episode specifiers apply to each codahlc Mood Disorder. Other specifiers describe the course of rothrrent mood episodes (i.e., Longitudinal Course Specifiers, With Seasonal Pattern, With Rapid Cycling}. Table 2 (p. 42-4) indicates which course Specific”: apply to each rodablc Mood Disorder. "l‘ he specifiers that indicate severity, remission, and psychotic fL‘fl- tures can be coded in the fifth digit of the diagnostic code for most of the Mood Dis- orders. The other specifiers cannot be coded. The Mood Disorders section is organized as follows: * Mood Episodes Maior Depressive Episode (p. 349} Manic Episode [3}. 357} Mixed Episode (p. 362) ilypomanic Episode (p. 365] * Depressive Disorders 296.xx Major Depressive Disorder tp. 369] 3100.4 Dystliymic Disorder (p. 3%) Sit Depressive Disorder Not Otherwise Specified (p. 381) o Bipolar Disorders I 296.50: Bipolar l Disorder tp. 382} 296.89 Bipolar II Disorder (p. 392] 301.13 Cyclothyniic Disorder (p. 398i u I“ 400 296.80 Bipolar Disorder Not Otherwise bpecitied (p. ) u d Disorders I J I I‘ 2:3; M‘tizod Disorder Due to. . .[liie'ictrie the General Medics. Cmrritttml (p. 401} 29x.xx Substance-Induced Mood Disorder (p. 405} 296.90 Mood Disorder Not Otherwise Specified (p. 410] d Specifiers describing the clinical slams of the current (or most recent] 11100 O I d ' ' ' . . . ' ‘- _ gills; hitodcrete. Severe Wiflioul Psychotic i'ealures, Severe With t’spcltgticia: miles In Partial Remission, in Full Remission (t'or Ma]or Depressive .pis , p. All; for Manic Episode, p. 413; for Mixed Episode, p. 4115} . _ .\ . f - Specifiexs describing features of the current episode, (or most recent episode I currently in partial or full remission) Chronic (p. 417,1 I Widi Catatonic Features (p. 412’] IWith Melanchoiic Features {p— 419} With Atypical Features tp. r120) With Postpartum Onset (p. 422) . . . des ' ' -descr1bin course of recurrent cplso I ‘ r I . laggiiiiadinal Coursegfipccifiers (With and Without Full lnterepisode Recot cry} ([3. 4241 F With Seasonat Pattern (p. 423} With Rapid Cycling (p. 42;} Recording Procedures for Major Depressive Disorder and Bipolar | and Bipolar ll Disorders Selecting diagnostic codes. The diagnostic codes are selected as follows: For Major Depressive Disorder: ' > ' ee L‘ii’lifi are 2%. n I I 1 :— rdigit either 2 (if there is only a single h-lsiorthapressivc Epi - sode‘i or 3 (it' there are recurrent Maior Dcpressrve Episol €55in FF} The fifth digit indicates the SEEFEiII'll'y ofltlttc .2ep; madame ' t riteria are met as o ows: or. t . _, I“ '- t(or Severe Without Psychotic Featu res, i for Spec-rel: chotic Features. 1t t'ull criteria are not currentlyr rnet for a trierf ([2121 M- hr l3 misode the fifth digit indicates the current clinirel status-o t is; [large— Dicprcssive Disorder as follows; 5 for In Partial RemiSSlDD:d(5 ($212“: dig” mission. It Current severity or clinical status is thlspeullt. , it. is 0. Pl MOOU Disorders For Bipolar [ Disorder: 1. 2. to '['he first three digits are also 296. The fourth digit is [} if there is a single Manic Episode. For recurrejjgep-t_ socies, the fourth digit indicates lhe nature of the current episode {on if {he Bipolar I Disorder is currently in partial (51' full remission, the nature of the most recent episode) as follows: 4 if Ihc current or most recent episode is a Hypomanic Episode or a Manic Episode. o it it is a Mixed Episode, 5 [f it is a Major Depressive Episode, and 7 if the. current or most recent epi- sode is Unspecified. The fifth digit {except for Bipolar [Disorder, Most Recent Episode Hypo. manic, and Bipolar I Disorder, Most Recent Episode Unspecified} indj. cates the severity of the Current episode if it!” criteria are met fOJ' a ManicJ Mixed, or Major Depressive Episode as lollnwsz 1 ft" Mild severity, 2 for Moderate severity, 3 for Severe Without Psychotic Features. 4 for &vere With Psychotic Features. lf full criteria are not met for a Manic, Mixed, or Major Depressive Episode, the fifth digit indicates the EU rrcni Clinical Sta. tus of the Bipolar l Disorder as follows. For ln Partial Remission. '3 I‘m“ in Full Remission. If current severity or clinical status is unspecified, the fifth dig-it is 0. For Bipolar l Disorder, Most Recent Episode t-Iypornanic, the filth digit is always (1. For Bipolar Disorder, Most Recent Episode Unspec. ified, there is 110 fifth digit. For Bipolar ll Disorder, the diagnostic code is 296.89. Recording the name a! the diagnosis. in recording the null“? of a diagnosis. terms should be listed in the following order: Serum Ur specifiers: Name of disorder Leg, \dajor Expressive Disorder, Bipolar Disorder) Specifiels coded in the fourth digit [e.g., Recurrent, Most Recent Episode lvtanic) Specifiers coded in the fifth digit leg... Mild, Severe With Psychotic Features, in Partial Remission} _ As many specifiers [wrthout codes} as apply to the current or most recent epi— Sude leg, 'With Melancholic Features, With Postpartum Onset) As many specifiers {without codes} as apply to the course of recurrent episodes {e.g., With Seasonal Pattern, With Rapid Cycling) The following examples illustrate how to record a Mood Disorder diagnosis with 0 296.32 Major Depressive Disorder, Recurrent, Moderate. With Atypical Features. Willi Seasonal Pattern, With Full lnterepisode Recovery 29(15-1 Bipolar l Disorder, Most Recent Episode Depressed, Severe With Psychot' ic Features, With Melancholic Features, With Rapid Cycling Major Depressive Episode Episode Features The essential feature of a Major Depressive Episode is a period of at least 2 weeks dur— jng which there is either depressed mood or the loss of inlerest or pleasure in nearly all activities. in children and adolescents, the mood may be irritable rather than sad. The individual must also experience at least four additional symptoms drawn from a list that includes cha ngcs in appetite or weight, sleep, and psychomotor activity; de- creased energy; feelings of worthlessness or guilt: difficulty thinking, concentrating, or making decisions; or recurrent thoughts of dead: or suicidal idealion, plans, or at- tempts/1'0 count toward a Major I'Jepressive Episode, a symptom must either be new- ly present or must have clearly worsened compared with the person's preepisarle. status. The symptoms must persist for most of the day, nearly every clay, for at least 2 mmecutivc weeks. The episode must be accompanied by clinically Significant dis‘ tress or impairment in social, occupational, or other important areas oF functioning. For some individuals with milder episodes, functioning may appear to be normal but requires markedly increased effort. The mood in a Major Depressive Episode is often described by the person as de- pressed, sad, hopeless, climouragcd, or "down in the dumps" (Criterion A1). In some cases, sadness may be denied at first, but may subsequently be elicited by interview [e.g., by pointing out that the individual looks as if he or she is about to cry]. In some individuals who complain of feeling "bl-ah,” having no feelings, or feeling anxious, the presence of a depressed mood can be inferred from the person’s facial expression and demeanor. Some individuals emphasize somatic complaints (e.g., bodily aches and pains) rather than reporting feelings of sadness. Many individuals report or ex- hibit increased irritability (e.g., persistent anger, a tendency to respond to events with angry outbursts or blaming others, or an exaggerated sense of frustration over minor matters}. in children and adolescents, an irritable or cranky mood may develop rather than a sad or deiected mood. This presentation should be differentiated from a "spoiled child" pattern of irritability when frustrated. Loss of interest or pleasure is nearly always present, at least to some degree. Indi- viduals may report feeling less interested in hobbies, “not caring anymore," or not feeling any enjoyment in activities that were previously considered pleasurable [Cr-id lerion A2). Family members often notice social withdrawal or neglect of pleasurable avocations (eg, a formerly avid golfer no longer plays, a child who used to enjoy soc— cer finds excuses not to practice}. In some individuals, there is a significant reduction from previous levels of sexual interest or desire. Appetite is usually reduced, and many individuals feel that they have to force themselves to eat. Other individuals. particularly those encountered in ambulatory settings, may have increased appetite and may crave specific foods leg, sweets or other carbohydrates]. When appetite changes are severe (in either direction}, there Mood Disorders may be a significant loss or gain in weight, or, in children, a failure to make ex weight gains may be noted [Criterion AB). Feel“ The most common sleep disturbance associated with a Major Depressive Epism is insomnia (Criterion A4,]. individuals typically have middle insomnia fie, Wald: up during the night and having difficulty returning to sleep} or terminal insgmmg (i.e., waking too early and being unable to return to sleep} initial insomnia lie. (1-: ficulty falling asleep} may also Occur. Less frequently, individuals present with L sleeping {hypersomnia} in the form of prolonged sleep episodes at night or increase: daytime sleep. Sometimes the reason that the individual seeks treatment is for the dis, turbed sleep. Psychomotor changes include agitation leg, the inability to sit still, pacing, lump wringing; or pulling or rubbing of the skin, clothing, or other objects) or retardation {e.g., stowed speech, thinking, and body movements; increased pauses before an. sivcring; speech that is decreased in volume, inflection, amount, or variety ofcontent or muteness) (C riterion A S}. The psychoinotor agitation or rcta rdation must be seven; enough to be observable by others and not represent merely subjective feelings. Decreased energy, tiredness, and fatigue are common (Criterion A6}. A person may report sustained fatigue. without physical exertion. Even the smallest tasks seem to require substantial effort. The efficiency with which tasks are accomplished may be reduced. For example, an individual may complaLn that washing and dressing—in the morning are exhausting and take twice as long as usual. The sense of worthlessness or guilt associated with a Major Depressive Episode may include unrealistic negative evaluations of one’s worth or guilty preoccupations or ruminations over minor past failings [Criterion A7]. Such individuals often mis- interpret neutral or trivial day-today events as evidence of personal defects and have an exaggerated sense of responsibility for untoward events. For example, a realtor may become preoccupied with self-blame for tailing to make sales even when the market has collapsed generally and other realtors are equally unable to make sales. The scn se of worthlessness or guilt maybe of delusional proportions (eg, an individ- ual who is convinced that he or she is personally responsible for world poverty). Blaming onesle for being sick and for Failing to meet occupational or interpersonal responsibilities as a result of the depression is very common and, unless delusional, is not considered sufficient to meet this criterion. Many individuals report impaired ability to think, concentrate, or make decisions {Criterion A8). They may appear easi iy distracted or complain of memory diffic ulties. Those in intellectually demanding academic or occupational pursuits are often unable to lunction adequately even when they have mild concentration problems [e.g., a computer programmer who can no longer perform complicated but previously man- ageable tasks). in children, a precipitous drop in grades may reflect poor concentra— tion. In elderly individuals with a Major Depressive Episode, memory difficulties may be the chief complaint and may be mistaken for early signs of a dementia (“pseudo- dementia"). When the Major Depressive Episode is successfully treated, the memory problems often fully abate. However, in some individuals, particularly elderlv per- sons, a Major Depressive Episode may sometimes be the initial presentation of'an ir- reversible dementia. _ Frequently there may be thoughts of death, suicidal ideation, or suicide attempts [Criterion A9). These thoughts range from a belief that others would he better off if Major Depressive Episode the Person were dead, to transaent 'uut recurrent thoughts of committing suicide, to act-Lia! specific plans of how to commit suicide. The frequency, intensity, and lethality of these thoughts can be quite variable. Less severely suicidal individuals may report iransient ('l- to 2-minutel, recurrent (once or twice a week] thoughts. More severely suicidal individuals may have acquired materials [e.g., a rope or a gun} to he used in the suicide attempt and may have established a location and time when they will be isolated from others so that they can accomplish the suicide. Although these behav- iors are associated Statistically with suicide attempts and may be helpful in identify- ing a highrrisk group, many studies have shown that it is not possible to predict accurately whether or when a particular individual with depression will attempt sui‘ Clde, Motivations for suicide may include a desire to give up in the face of perceived msurinowitable obstacles or an intense wish to end an excruciatingly painful emo- tional state that is perceived by the person to be without end. A diagnosis of a Major Depressive Episode is not made if the symptoms meet cri- teria for a Mixed Episode {Criterion B}. A Mixed Episode is characterized by the symptoms of both a Manic Episode and a Major Depressive Episode occurring nearly every day for at least a 1—week period. The degree of impairment associated with a Major Depressive Episode varies, but even in mild cases, there must be either clinically significant distress or some interfcrv ence in social, occupational, or other iittportant areas of functioning {Criterion C). If impairment is severe, the person may lose the ability to function socialhr or occupa- tionally. in extreme cases, the person may be unable to perform minimal self-care (cg, feeding or clothing self} or to maintain minimal personal hygiene. A careful interview is essential to elicit symptoms of a Major Depressive Episode. Reporting may be compromised by difficulties in concentrating, impaired memory, or a tendency to deny, discount. or explain away Symptoms. information from addi- tional informants can be especially helpful in clarifying the course of current or prior Major Depressive Episodes and in assessing \vhelitet' there have been an},r Manic or l-Iypoinanic Episodes. Because Major Depressive Episodes can begin gradually, a re- view of clinical information that focuses on the worst part of the current episode may be most likely to detect the presence of symptoms. The evaluation of the symptoms of a Major Depressive Episode is especially difficult when they occur in an individual who also has a general medical condition (0.5., cancer, stroke, myocardial infarction. diabetes]. Some of the criterion items of a Major Depressive Episode are identical to the characteristic signs and symptoms of general medical conditions [e.g., weight loss with untreated diabetes, fatigue with cancer). Such symptoms should count toward a Major Depressive Episode except when they are clearly and fully accounted for by a general medical condition. For example, weight loss in a person with ulcerative coli— tis who has many bowel movements and little food intake should not be counted to ward a Major Depressive Episode. On the other hand, when sadness, guilt, insomnia. or weight loss are present in a person with a recent myocardial infarction, each symp- tom would count toward a Major Depressive Episudc because these are not clearly and fully accounted for by the physiological effects of a myocardial infarction. Simi‘ larly, when symptoms are clearly clue to mood-incongrucnt delusions or hallucina— tions {e.g., a 30‘pour1d weight less related to not eating because of a delusion that one's food is being poisoned), these symptoms do not count toward a Major Depres- sive Episodc. 11 ll wmw Econ 9833 _ may gmmamoP m Km“? Umfimmmmmg mfimomm a 50.“ Q55 3 Em mwmmn» firwmmowommnfl mm. 39m om m Qmsm 0m £33 3%: 5 m8 838i om minorom Fwoanwmon 0H. 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Gaga C393 mmmam MD mofi SE» m W335 335” @3me 83$ 9me : Huron, 05:: $3” Swim mmwcm W .5 m nmcmm d, was: Mood Disorders every day for at least 2 weeks). and clinically significant (llSIi‘ESS or impairment Th diagnosis Depressive Disorder Not Otherwise Specified may be approprian'e f e presentations of depressed mood with clinically significant impairment that d‘ or meet criteria [or duration or severity. a not Criteria for Major Depressive Episode m A. Five [or more: of the following symptoms have been present during the same 2-week period and represent a change from previous functioning: at least one of the symp. toms is either it) depressed mood or {2} loss of interest or pieasure. Note: Do not include symptoms that are ciearly due to a general medical Candi. tron, or mood-incongruent delusions or hailucinations. {ii depressed mood most of the day, nearly every day, as indicated by either sub. jective report te.g.. feels sad or empty) or observation made by others leg, ap— pears tearfut). Note: In children and adolescents. can be irritable mood. t2) markedly diminished interest or pleasure in all, or almost all, activities most of the day. nearly every day {as indicated by either subjective account or observa. tion made by others) t3) significant weight loss when not dieting or weight gain (cg, a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. [4) insomnia or hypersomnia nearly every day (5) psychomotor agitation or retardation nearly every day iobservable by others. not merely subjective feelings of restlessness or being slowed down} {6) fatigue or loss of energy nearly every day {It} feelings of worthlessness or excessive or inappropriate guilt {which may be de- lusional} nearly every day (not merely self-reproach or guilt about being sick) {8} diminished ability to think or concentrate. or indecisiveness, nearly every day (either by subjective account or as observed by others) {9} recurrent thoughts of death [not just fear oi dying}, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide 8. The symptoms do not meet criteria for a Mixed Episode {see p. 365]. C. The symptoms cause clinically significant distress or impairment in social, occupationv al, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance tag, a drug of abuse, a medication) or a general medical condition {e.g., hypothyroidism]. E. The Symptoms are not better accounted for by Bereavement. i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness. suicidal ideation, psychotic symptoms. or psychomotor retardation. —-——.——— l l | l l l l | | Manic Episode Manic Episode Episode Features A Manic Episode is defined by a distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood. This period of abnormal mood must last at least 1 week (or less. if hospitalization is required} {Criterion A). The mood disturbance must be accompanied by at least Ll-u-ee additional symptoms from a list that includes inflated self-esteem or grancliosity, decreased need for sleep, pressure of speech, Flight or ideas, distractibility, increased involvement in goal‘ directed activities or psychonmtor agitalinn, and excessive involvement in pleasur- abk- activities with a high potential for painful consequences. If the moucl is irritable (rather than elevated or expansive), at least four of the above symptoms must be present {Criterion Is). The symptoms: do not meet criteria for a Mixed Episode, which is characterized by the symptoms of both a Manic Episode and a Major Depressive Episode occurring nearly everyday for at least a 1-week period [Crilot'ion C]. The dis- turbance must be sufficiently severe to cause marked impairment in social or occupa- tional functioning or to require hospitalization, or it is characterized by the presence of psychotic features (Criterion D}. The episode must not be clue to the direct physi- ological effects of a drug of abuse, a medication, other somatic treatments for depres— sion {e.g., electroconvtiisive therapy or light therapy), or toxin exposure. The episode must also not be due to the direct physiological effects of a general medical condition (6.3., multiple sclerosis, brain tumor] (Criterion E]. The elevated mood of a Manic Episode may be described as euphoric, unusually good, cheerful, or high. Although the person's mood may initially have an infectious qualily for the uninvolved observer, it is recognized as excessive by those who know the person well. The expansive quality of the mood is characterized by unceasing and indiscriminate enthusiasm for interpersonal, sexual, or occupational interactions. For example, the person may spontaneously start extensive conversations with strangers in public places, or a salesperson may telephone strangers at home in the early morn- ing hours to initiate sales. Although elevated mood is considered the prototypical symptom, the predominant mood disturbance may be irritability, particularly when the person's wishes are. thwarted. Labiliiy of mood (tag, the alternaLion between eti- phoria and irritability} is frequently seen. Inflated self-esteem is typically present, ranging from uncritical sell-confidence to marked grandiosity, and may reach delusional proportions [Criterion Bl). Individu- als may give advice on matters about which they have no special knowledge {e.g.. how to run the United Nations). Despite lack of any particular experience or talent. the individual may embark on writing a novel or camposing a symphony or seek publicity for some impractical invention. Grandioee delusions are common [e.g., hav- ing a special relationship to God or to some public figure from the political, religious. or entertainment world). Almost invariably, there is a decreased need for sleep [Criterion 32). The person usually awakens several hours earlier than usual. feeling full of energy. When the sleep disturbance is severe, the person may go for clays without sleep and yet not feel tired. i l Mood Dimmers Manic speech is typically pressured, loud, rapid and di on B3). Individuals may talk nonster mm“ to interrupt [Criterj_ 5 . . 3am! for "thci’S' Wifihes tocornmunic it gmehrs mr hours on und’ and “'illiout ' 'e 9- L’i‘f‘ l5 - ' . re. ptiiining,and amnsin - . ,_ _. P - E"W'fllmfls Cilaractefl-LE - . mam mannerisms a int-c ley ancies. The individual mm.- bewme iheam (:11)? lit-king, . . n . l n 1. Singing. Sounds rather than meaningful IILIIICCIJI‘ ,Imth cit-,1. L “3 r'l‘lt‘tlio n. Ships may govern - . \ word Cholc‘ ' a t - than expanswe 5 each t (LI-u Hanging]. Ifllieperson‘s mood is mo- ' ' l P may he mark“ [‘Y complaints K m Irritable . tii'ades. hostile comments, or angry Them ' ,' . 1.. dn id ital s thoughts may race, often at. u rah? hster th . i erion ).SCI]TIL:IH l\’ LIZI ‘rW' VI Lit [' Lit. rt I I34 (1 Kl i. lll'l a I I ' “I I I l .pli-D ‘5 I'EPU that an can be articulated (Cri. : I _ thisex eri ‘ - » “ideas mdemm 1w gym pro-grams simultaneously. Frequgfimfgig: Changes from one IOP,IC In an 3; continuous flow of accelerated spefidh mm 1) 13m ness deal to sell computers d:;:- For example, while talking about a potenti 131 but? history of the computer chi, t] .Sperml‘ may Shift to discussing in minute det 'lUSI- night of Ideas Issevere, 5P(’Eéh‘fIiInIdbustnal reyoiution, or applied mathematics. Edie I Distractibllity {Criterion {£5} isljnrga‘iize‘l in“ “Wham-nt- n external stimuli (eIgII the interviewer’s fie I )‘kfln Inability. Illl'njshrngs 'm the room}_ There may be . Jac ground thoughts that are germane to the m i ' clearly irrelevant. P c an to screen out irrelevant noises or conversatio ‘ I I . ms or a . . d threduced ability to difterentiate betwcen oughts that are only slightly relevant or he Int lease Ill 303 ‘ Ii all. Ii 1 i CI t.‘ 'IVC \ ‘3 en WE la r! n lex- . . l H n [I J! E‘.‘ (’SSl l‘tm i l (l 82th l l p g 0 . a t cessii'c partici stio ' ' n . r ' -' ' gIDIIS) IICUIIII In_ multiple activities {e.g., sexual occu nr'o ] ' ' .rton B6). Increased sexual drive E I l‘ 1 “a (pelmmllmu- ares: ' , _. . ‘liltasid . . ,- 1 m" rhe pm’m‘ ma)” sunultaneousiy ‘ 3‘ and h‘h‘mor are often without r_ . _ {like on mulii in n - .. . egald for the apparent risks or the need Io comileteew [bummbh wumrcs eat: 1 Venture toril -. . ‘ ' v ' ' tam; :rlmonIt myariabiy. then: is increased sociability te v r a m In I I I t _ . ., em.- IIegard I0 the IEIISSInds :r 91:2“ strangers at all hours oi Ere day or ni l t ' InIIIIIIIIdIII-IIS BIKINI-III lei I omineermg, and demanding nature oi theses] L Wir'hom sp ay psychornotor agitation or restlessness by _' mmmcmns‘ \. pacmg or by hold— ing inulti is mine ' ' "' same III-“:3 SO I IrsaItiIons simultaneously log, by telephone ani ' I I . I rue 1l1d1\- it‘lLlfllS write a torrent of let: ' L In Person at the riLEnds, public figures, or the media e” on m 'I. an ' " - p Siveiiess, unwarranted optimism grandiosi lead to a“ - lmprudent inuoi‘re. - nent i ' . . reckless (ii-living, '1 P'E‘aburabic satisfac- Wing old acquain. any different topics to and poor iudgnient often IOOIISII busmesq IIIIIESI I activities such as buying sprees, PEGOIII even Ihough these NIIVIEIEQ are Fiery”, aid sexual behavior unusual for the . - l e v to ave painful i: , onsequences (Criteri- (ill B? l. Ihe EndtV'JdL :11 may Purtllxlse ] lrlll)‘ unneeded llL’ltlS (0. . 20 )all’s (If SllOES t 3!. ; ’xpellSlVE anti Lies \ ' may include infidellt filth-Duhmé "lone-V to Pay for them- Unusual sexl l b I ‘ The Imp I ) or indiscriminate sexual “Wilmer.” ith E "1 “WIN airment resulting fv . - V s rangers -~ 10m the dist b. .. - marked impair- ' - "r “we must be we - merit [ - . \ ‘CTO enou h ~ ‘ vidual from Ihe n it EunCHUI'Ilng or to require hospitalization to if; to hm“? agar“? consequmceS of actions “m I pro Let the inch. resu t e_ _ - . a _ - . l g . flnanmal 1035135 magi“ activitiefl 1mm Pour [udgmcnt . _ _ loss. f '- definition 11 . s . n Ln'llz’lolm'lm'tl:c'lE‘n‘it ‘ - - marked I J 1Ie PmsLInCL of psycho“: features dun“ ’ II M I Iiullive behavior). 5),. '"‘Pfl'l'mt'nlm functioning [CI-item,“ D) b ‘ ‘ m“ LP‘SWE Cunstilutes yinploms 1 C [11056 ‘a l‘(‘ll In a \a arm lplhn i? ind} be flUi,‘ [0 the direct L‘fft‘t S f S k I l d l O Manic Episode antidepressant medication. electroconvulsive therapy, light therapy, or medication prescribed for other general medical conditions leg, corticosteroids]. Such presenta- firms are not considered Manic Episodes and do not count toward the diagnosis of Bipolar] Disorder. For example, if a person with recurrent Major Dcpre sive Disorder develops manic symptoms tollowing a course of antidepressant medication, the epi— sode is diagnosed as a Substance-Induced Mood Disorder, With Manic Features, and there is no switch from a diagnosis of Maior Depressive Disorder to Bipolar I Dis— order. Some evidence suggests that there may be a bipolar “diathesis” in individuals who develop manicllike episodes following somatic treatment for depression. Such individuals may have an increased likelihood of future Manic, Mixed, or Hypdmanic Episodes that are not related to substances or somatic treatments for depression. This may be an especially important consideration in children and adolescents. Associated Features and Disorders Associated descriptive features and mental disorders. individuals with a Manic Episode frequently do not recognize that they are ill and resist efforts to be treated. They may travel impulsively to other cities, losing contact with relatives and caretak- ers. They may change their dress, makeup, or personal appearance to a more sexually suggestive or dramatically flamboyant style that is out of character for them. They may engage in activities that have a disorganized or bizarre quality Le.g., distributing candy, moneyr or advice to passing strangers). Gambling and antisocial behaviors may accompany the Manic Episode. Ethical concems may be disregarded even by those who are typically very conscientious legs a stockbroker inappropriately buys and sells stock without the clients’ knowledge or permission: a scientist incorporates the findings of others). The person may be hostile and physically threatening to others. Some individuals, especially those with psychotic features. may become physically as- saultive or suicidal. Adverse consequences of a lV-lanic Episode (rugs involuntary hos— pitaiizalion, difficulties with the law, or serious financial difficulties) often result from pom ludgrnent and hyperactivity. When no longer in the Manic Episode, most individuals are regretful [or behaviors engaged in during the Manic Episode. Some individuals describe having a much sharper sense of smell, hearing, or vision (e.g., colors appear veryr bright}. When catatonic symptoms {e.g., stupor, mutism, negativ- ism, and posturing) are present, the specifier With Cataronic Features may he indicat- ed (see. p. 41?}. Mood may shift rapidly to anger or depression. Depressive symptoms may last moments, hours, or, more rarely, days. Not uncommonly, the depressive symptoms and manic symptoms occur simultaneously. It the criteria for both a Major Depres- sive Episode and a Manic Episode are prominent every day for at least L week, the episode is considered to be a Mixed Episode (see p. 362). As the Manic Episode dev velops, there. is often a substantial increase in the use of alcohol or stimulants, which may exacerbate or proiong the episode. Associated laboratory findings. No laboratory findings that are diagnostic of a Manic Episode have been identified. However, a variety of laboratory findings have been noted to he abnormal in groups of individuals with Manic Episodes compared with control subjects. Laboratory findings in Manic Episodes include polysomnographic l g. If i It mood Dlsf-‘I'Clers Criteria for_ m A. A distinct - period of abnoj-m ally and ' mead. laslin at PQ'S'S‘CNIY eievated e - 9' least 1 week [or any duration it hospitalizaijozfijnswe‘ necess E1. During the period of mood disturbance have persisted [tour if the mood is o l I' cant degree: n y l or irritable all“). three {or more: of , the following 5 m t rritahle) and have been present to: slug? {1) inflated self-esteem or grandiosit {2) decreased need for sleep (e. y -. i I l3} more talkative than usual 9 EE 5 “mad afle’ unlit 3 hours of map; (4} m ht I I I orpressureto kee talk' 9 of ideas or SUijC‘lIVE experience that Enough": ar e racing (5) di t ' ' ' ' ' s ractrpility {n.e., attentlon too easil dr ' tamer Stu-nu”) y awn to unimportant or (6) increase in goal»directed activit or psychomotor agitation t?) excessive inv ' olvernent in pleasurable activities that have a high t on ential tor painful consequen :95 (eg engagjn - ‘ - . " 9 In unrest ' ‘ discretions. or foolish business investments] Famed buying sprees. sexilaf in. lf'ElEVant ex. y {either socially, at work or school or sexually) C. The symptoms d o not meet criteria for a M' used Episode {see p. 365}. D. The mood disturbance is sufficientl tronal functioning or in usual socia cessitate hospitalization . to tealures. maven SEVEN? [0 Ca SE I'D r c m a fr‘l'1El t n (it a— ‘f c U a k d P | (up la {IV ties Cll' relat onshr) 1 I?! or n - |S W h D‘th 5. to E l l allt 10 se DI OtlIQI‘S. DI than? are pSyClIDIIC E. Lhe symptoms are not due to the direct rug of abuse, a medication, or other (e.g.. hyperthyroidism}. tphysiological effects of a substance [e g a eatment} or a general medical condition Note: Manlcv Ike 9 I a D a a H I' - p sodes 1h ‘l are clearly caused by S m lit r t dopre T ssan i. eat I‘ El 1 (9.9. medication e E: v e a I h s . . l trocon ulsiv t 1 er )5 I I 2' th pl); 9 3ij.I ho‘ [d no to m: tov.a (‘l a dlagr 0515 D Bipolar l DISOI’dC‘r r l h _______________—___h Mixed Episode Episode Features AMlxud E isodeisch ‘ 1. I I [he crthriaPam mot hjjfiiLfrrI-iefdbtla Period of time (lasting at least 1 week] ' , . nearly overj- dd}. [criterion 3: air-11C Pip-ISon and {of a Major DepresgivetgtlthJ-Ch (sadnesi iri‘lmbilllt’ eniho ' " hfmdmdu‘“exPEriencesi-apidlv alteriiad Plsmlu P' am and a Mal-0T- bailing} :Ec'ompanlfll by E‘le‘tfi‘h'ifi of a Manic E Ergo-ms ‘iuently includes agitation‘inq: lplsude (5“? P- 349). The symptom preqegm. L liee sulddal “linking- Il‘he dislurBaEH-llal appemc dl’srcgulation. psychoticteat-(Lit1 Em m:- Palmleflt in social or occ‘u [' 0L musr.bc_suffidemly SEVEN-1 tn mus ' ‘5' 5.1m pa Iona! functioning or to requir- liuspihljy:::rkml lm‘ ‘ - n. or it is ManicEpiscjde - .. fl Mixed Episode esence of psychotic features (Criterion E]. The disturbance is siological effects of a substance (0.3., a drug of abuse, a mac - neral medical condition te.g., hyperthyroidism] i in a Mixed Episode may be due to the direct electi'oconvulsive therapyr light therapy, or 1 medical conditions [_e.g., corticosteroids). d Episodes and do not count toward a di- it' a person with recurrent Major Depres- cltaracterized by the pr not due to the direct phy imtion. or other treatment] or a ge (Criterion C]. Symptoms like those see: cilects of antidepressant medication, medication prescribed for other genera Such presentations are not considered Mince agnosis of Bipolar i Disorder For example, give Disorder develops a mixed symptom picture during a course of antidepressant medication, the diagnosis of the episode is Substancwlnduced Mood Disorder. With Mixed Features, and there is no switch from a diagnosis of Major Depressive. Disorder to Bipolar i Disorder. Some evidence suggests that there may be a bipolar “cliathesis” in individuals who develop mixed-like episodes following somatic treatment for ale-- pression. Such individuals may have an increased likelihood of future Manic, Mixed, nr Hypomanic Episodes that are not related to substances or somatic treatments tor depression. This may be an especially important consideration in children and ado- iescenls. Associated Features and Disorders Associated features of a and Major Depressive Epi— behavior. Because in- an do those in Manic c! descriptive features and mental disorders. to those for Manic Episodes disorganized in their thinking or rice more dysphoria th Associate Mixed [Episode are similar sodes. Individuals may be dividnals in Mixed Episodes experic Episodes, they may be more likely to seek help. Associated laboratory findings. Laboratory findings for Mixed Episode are not well studied, although evidence to date suggests physiological and endocrine findings that are similar to those foimd in severe Major Depressive Episodes. Specific Culture, Age, and Gender Features Cultural considerations suggested for Major Depressive Episodes are relevant to Mixed Episodes as well (see p. 353). Mixed ep dividuals and in individuals over age as ye younger in ales. may be more common in males than in fem Course Mixed Episodes can evolve from a M sode or may arise de novo. 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Atteniion-Deficitr’l-[yperactivity Disorder is distinguished from a Hm 0f manic Episode by its characteristic early onset (i.e., before age 7 years.) chronic rig:— than episodic course, lack of relatively clear onsets and offsets, and the absence of I normally expansive or elevated mood. ab‘ I A Hy'pomanic Episode must be distinguished from enthymia, particularltr in ind' VldLlalziu who have been chronically depressed and are unaccustomed to the ex once of a nondeprcssed mood state. I Pen- Criteria for Hypomanic Episode A. A distinct period of persistently elevated. expansive, or irritable mood lasting throughout at least 4 da 5, that is clea | ' mead. y r y different from the usual nondepressgd During the period of mood disturbance, three (or more} oi the toliowing symptoms ave perSIsted f OH I 0 15 {ill ‘f If! a e} 3‘“? 9211 DIGSE Cl a - h f ftlenod [bl andh b If f c { Slgm i in inflated self-esteem or grandiosity (2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep} (3} more talkative than usual or pressure to keeo talking [4) flight of ideas or subjective experience that thoughts are racing [5) distractibilitv {i.e., attention too easily drawn to unimportant or irrelevant ex- ternal stimuli]! {6) increase in goal-directed activity (Either socially, at work or school, or sexually} or psychomotor agitation {7} excessive invoivernent in pleasurable activities that have a high potential for painful consequences leg, the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments) The episode is associated with an unequivocal change in functioning that is unchar- acteristic of the person when not symptomatic. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupa- tional functioning, or to necessitate hospitalization. and there are no psychotic fea‘ tunes. I The symptoms are not due to the direct physiological effects of a substance {e.g., a drug of abuse, a medication, or other treatment! or a general medical condition (e.g., hyperthyroidism}. Note: Hypon‘lanic‘like episodes that are clearly caused by somatic antidepressant treatment te.g.. medication, electroconvulsive therapy, light therapy} should not count toward a diagnosis of Bipolar ll Disorder. _—-————_—— Depressive Disorders Depressive Disorders Major Depressive Disorder Diagnostic Features The essential feature of Major Depressive Disorder is a clinical course that is charac- terized by one or more Major Depressive Episodes (see p. 349) without a history of Manic, Mixed, or Hypumanic Episodes [Criteria A and C}. Episodes oi Substance- Induced Mood Disorder (due to the direct physiological effects of a drug of abuse, a medication, or toxin exposure} or of Mood Disorder Due to a General Medical Con- dition do not count toward a diagnosis of Major Depressive Disorder. In addition, the episodes must not be better accounted for by Schizoat't'ectivc Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disnrder, or Psychotic Disorder Not Otherwise Specified (Criterion B). The fourth digit in the diagnostic corie for Major Depressive Disorder indicates whether it is a Single Episode (used only for first episodes} or Recurrent. [t is some- times difficult to distinguish between a single episode with waxing and waning symptoms and two separate episodes. For purposes of this manual, an episode is con- sidered to have ended when the full criteria for the Major Depressive Episode have not been met for at least 2 consecutive months. During this 2-month period, there is either complete resolution oi symptoms or the presence of depressive symptoms that no longer meet the full criteria for a Major Depressive Episode {In Partial Remission). The fifth digit in the diagnostic code for Major Depressive Disorder indicates the current state of the disturbance. If thr- criteria fora Major Depressive [Episode are ntel, the severity of the episode is noted as Mild. Moderate, Severe Without Psychotic Fea- tures, or Severe With Psychotic Features. If the criteria for a Major Depressive Epi- sode are not currently met, the iifth digit is used to indicate whether the disorder is in Partial Remission or in Full Remission {see p, 412}. if Manic, Mixed. or Hypomanic Episodes develop in the course of Major Depres- sive Disorder, the diagnosis is changtxl to a Bipolar Disorder. However, if manic or hypomanic symptoms occur as a direct effect of antidepressant treatment, use of oth- er medications, substance use, or toxin exposure, the diagnosis of Major Depressive Disorder remains appropriate and an additional diagnosis of Substance-induced Mood Disorder, With Manic Features [or With Mixed Features}, should he noted. Similarly, if manic or hypomanic symptoms occur as a direct effect of a general IIIEt'Ir icai condition, the diagnosis of Maior Depressive Disorder remains appropriate and an additional diagnosis of Mood Disorder Due to a General Med ical Condition, With Manic Features; (m— With Mixecl Features). should be noted. Specifiers It the full criteria are currently met for a Major Depressive Episodic, the following specifiers may be used to desCribe the current clinical status of the episode and to de- scribe features of the current episode: ._ Mood Disorders p1 condition (e.g,_ [111511315011 is based aged that the de— 9 general med— 1 (e.g.. Major an Axis III (eg.r Major Depressive ' wing- the general @Major Depres~ jor Depressive jag, a drug of related to the Qqcut‘s only in the Induced Mood hated based on , the depressed 5. 'od of at least then not over . 'c Disorder tthat the two in onset, du— .Usuall}.r Ma- ve Episodes Dysthymic ms is of suf- ode, the diag— ' till met], or Depressive rmic Sl'mP‘ isode (i.e., be at least - tmood elusional |y,sud1 - and do 'meet full : ce),adi. dil-ion to ‘Noioih. Major Depressive Disorder Major Depl‘eb 'vc‘ Disorder. With Catatcinic Features. Prior history or family history may be helpful in makuig this distinction. to elderly individuals. ii is often difficult to determine whether cognitive symp- toms ((3.5, disorientation, apathy, difficulty concentrating, memory loss} on: better accounted for by a dementia or by a Major Depressive Episode in Major Depressive Disorder. This diilerentia] diagnosis may be in formed by a thorough general medical evaluation and consideration of the Onset of the disturbance, temporal sequencing of depressive and cognitive symptoms, conrse of illness, and treatment response. The premorbid state of the individual may help to differentiate a Major Depressive Dis- order front dementia. In dementia: there is usually a prcmcrrbio' history at declining cognitive function. whereas the individual with Major Depressive Disorder is much more likely to have a relatively normal premoroid state and abrupt cognitive riecline associated with the depression. Diagnostic criteria for 296.2x Major Depressive Disorder, Single Episode A. Presence at a single Major Depressive Episode {see p. 356}. B. The Major Depressive Episode is not better acceninted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniiorm Disorder. Delusion-at Disorder, or Psychotic Disorder Not Otherwise Specified. C. There has never been a Mank Episode {see p. 362), a Mixed Episode (see p. 365), or a Hypomanic Episode {see p. 368}. Note: This exclusion does not apply if all of the manic-like. mixed-like, or hypomanic-like episodes are substance or treatment in- duced or are due to the direct physiological effects of a general medical condition. If the full criteria are Currently met For a Major Depressive Episode, specify its current ciinical status antlr'or features: Mild. Moderate, Severe without Psychotic FeaturesiSevere With Psychotic Features (see p. 412] Chronic (see p. 41?] With Catatonic Features (see p. 41 it} With Melanchollc Features {see p. 4191 With Atypical Features tsec p. 420} With Postpartum Onset {see p. 422) If the full criteria are not currently met for a Major Depressive Episode, specify‘tl'ie cur- rent clinical status of the Major Depressive Disorder or features of the most recent epiv sclcle.‘ tn Partial Remission, In Full Remission (see p. 4121 Chronic (see p. 41?} With Catatonic Features (see p. 41?) With Melancholic Features tsee p. 419} with Atypical Features (see p. 420} with Postpartum Onset [see p. 422} Y— Mood Disorders Diagnostic criteria for 296.33: Major Depressive Disorder, Recurrent A. Presence of two or more Major Depressive Episodes (see p. 356}. Note: To be considered separate episodes. there must be an interval of at least 2 consecutive months in which criteria are not met for a Major Depressive Episode. 5. The Maior Depressive Episodes are not better accountEd for by Schizoaifective Dis- order and are not superimposed on Schizophrenia, Schizophreniforrn Disorder, De. lusional Disorder, or Psychotic Disorder Not Otherwise Specified. c, There has never been a Manic Episode {see p. 362}. a Mixed Episode {see p. 365). or a Hypomanic Episode [see p. 368]. Note: This exclusion does not apply if all of the manic-like, mixed-like. or hypomanic-Iike episodes are substance or treatment in- duced or are due to the direct physiological effects of a general medical condition. If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status ancir'or features: Mild. Moderate. Severe Without Psychotic Features! Severe with Psychotic Features (see p. 412] Chronic [see p. at?) with Catatonic Features (see p. 41?) With Melancholic Features (see p. 419] With Atypical Features [see 5:. £20) With Postpartum Onset {see p. 422] If the full criteria are not currently met for a Major Depressive Episode, specify the cur- rent clinical status of the Maior Depressive Disorder or features of the most recent epi- sode: In Partial Remission, in Full Remission (see p. 412: Chronic (see p. 41?) with Catatonic Features [see p. 4]?) with Melancholic Features (see p. 419} with Atypical Features [see p. 420] With Postpartum Onset {see p. £22] Specify.- Longitudinal Course Specifiers (with and without lnterepisode Recovery] (see p. 424) With Seasonal Pattern (see p. 425] 300.4 Dysthyrnic Disorder Diagnostic Features The essential feature of Dysthymic Disorder is n cI'IrtJnica‘lljrI depressed mood that oc— curs for most of the clay more days than not for nl least 2 years [Criterion A]. individ- 300A Dysthymic Disorder unis with Dysthymic Disorder describe their moor] as and or "down in the clumps.“ Ln chiidren, the mood may be irritable rather than depressed, and the required mini- mum duration is only l year. During periods of depressed mood, at least two of the failuwing additional symptoms arc: present: poor appetite or overeating, insomnia or hypersomma. low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness [Criterion l3}. individuals may note the From'mcnt presence of low interest and self-criticism, often seeing themselves as un- jmemsting or incapable. Because those symptoms have become 5-0 much a part of the individuai's ciay—to-day experience tag, " l'vc always been this way," “'i'hat's just how 1am"), they are often not reported unless directly asked about by the interviewer. During the 2—year period {1 year for children or adolescents}, any symptom—free in- tervals last no longer than 2 months (Criterion (I). The diagnosis of Dysthymic Dis- order can be made only if the initial Evy-ear period of dysrhymic symptoms is free of [x-I-ttjor Depressive Episodes {Criterion B). if the chronic depressive symptoms include .1 Major Depressive Episode during the initial 2 years, then the diagnosis is Major De‘ pressivc Disorder, Chronic (it full criteria for a Major Depressive Episode are met), or Major Depressive Disorder, In Partial Remission [if full criteria for a Major Depres- sive Episode are not currently met). After the initial 2 years of the Dysthyntic Dis- order, Major Depressive Episodes may be superimposed on the Dysthymic Disorder. In such cases (“double depression"), both Major Depressive Disorder and Dysthymic Disorder are diagnosed. Once [he person returns to a dysthymlc baseline [1.C'., criteria for a Major Depressive Episode are. no longer met but tlysthymic symptoms persist}, onlyr l')ysthymic Disorder is diagnosed. The diagnosis of Dysthymic Disorder is not made if the individual has ever had a Manic Episode ('5). 35?}, a Mixed Episode (p. 362), or a Hypotnanic Episode (p. 365} or if criteria have ever been met for Cyclolhymic Disorder [Criterion [E]. A separate diagnosis of Dysthymic Disorder is not made if the depressive symptoms occur ex— citisively during the course of a chronic Psychotic Disorder, such as Schixophrcnia or Delusional Disorder (Criterion F}, in which case they are regarded as associated fea— tures of these disorders. Dvsthymic Disorder is also not diagnosed if the disturbance is due to the direct physiological effects of a substance [e.g., alcohol, antihypertensive medications} or a general medical condition leg, hypothyroidism, Alzheimer's dis— ease} {C riterion G). The 3y mptm'ns must cause clinically significant distress or impair- ment in social, occupational {or academic), or other important areas of functioning [Criterion H]. Specifiers Age at onset and the ('l‘laractm‘istic pattern of symplums in Dysthymit‘ Disorder may his indicalecl by using the following specifiers: Early Onset. This specifier should be used it' the onset of the dysthymic symptoms occurs before age 2] years. Such individuals are more likely to de- vclop subsequent Maior Depressive Episodes. Late Onset, This specific:- should he used if the onset of the dyslhymic symp— toms occurs at age 21 or older. With Atypical Features. This specifier should be used if the pattern of symp- Mood D isorders Depressive symptoms may be. a common associated feature of chronic Psychotic Disorders 02.3., Schizoaffcclive Disorder. Sciuzophrenia Delusional Disorder). A sep— arate diagnosis of Dysthymic Disorder is not made if the symptoms occur only during the course of the Psycholic Disorder {including residual phases). Dysthymic Disorder must be distinguished from a Mood Disorder Due to a Gen- eral Medical Condition. The diagnosis is Mood Disorder Due to a General Medical Condition, With Depressive Features. if the mood disturbance is judged to he the di- rect physiological consequence of a specific. usually chronic. general medical condi- tion (e.g.. multiple. sclerosis) {see p. 401]. This determination is based on the history. laboratory findings. or physical examination. if it is judged that the depressive symp- toms are not the direct physiological consequence of the general medical condition. then the primary Mend Disorder is recorded on Axis I Leg... Dysthymic Disorder) and the general medical conditimi is recorded on Axis III (c.g., diabetes mellitus). This would be the case. for example, it the depreSsive symptoms are considered to he the psychological consequence of having a chronic general medical condition or if there is no etiological relationship between the dcpmssive symptoms and the general med- ical condition. A Substance-Induced Mood Disorder is distinguished from a Dysthy- mic Disorder by the fact that a substance (0.3.. a drug of abuse. a medication, or exposure to a toxin} is judged to be etiologic-ally related to the mood disturbance {see p. 405]. Often there is evidence of a coexisting personality disturbance. When an individ— ual's presentation meets the criteria for both Dysthymic Disorder and a Personality Disorder. both diagnoses are given. Diagnostic criteria for 300.4 Dysthymic Disorder A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others. for at least 2 years. Note: ln chiidren and adolescents, mood can be irritable and duration must be at least 1 year. 8. Presence. while depressed. of two (or more] of the foilowing: (I) poor appetite or evereating (2] insomnia or hypersomnia (3} tow energy 0r fatigue (4) low self-esteem (5] poor concentration or difficulty making decisions {6} feelings of hopelessness C. During the 2—year period {! year for children or adolescents) of the disturbance. the per- son has never been without the symptoms in Criteria A and B for more than 2 months at a time. D. No Major Depressive Episode (see p. 356) has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not bet- ter accounted for by chlonic Major Depressive Disorder. or Major Depressive Disor- der. In Partial Remission. 311 Depressive Disorder Not Otherwise Specified Diagnostic criteria for 300.4 Dysthymic Disorder (continued) Note: There may have been a previous Major Depressive Episode provided there was a full remission (no significant signs or symptoms for 2 months] before develop- ment of the Dysthymic Disorder. In addition, after the initial 2 years {1 year in chil- dren or adolescents] of Dysthymic Disorder. there may be superimposed episodes of Major Depressive Disorder. in which case both diagnoses may be given when the cri- teria are met for a Major Depressive Episode. 5_ There has never been a Manic Episode (see p. 362). a Mixed Episode [see p. 365}. or a Hypomanic Episode {see p. 368). and criteria have never been met for Cyclothymlc Disorder. F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder. such as Schizophrenia or Delusional Disorder. 9 The symptoms are not due to the direct physiological effects of a substance (e.g.. a drug of abuse. a medication] or a general medical condition (2.9. hypothyroidism). H. The symptoms cause clinically significant distress or impairment in social. occupation- al. or other important areas of functioning. Specify if: Early Onset: if onset is before age 21 years Late Onset: if onset is age 21 years or cider Specify {for most recent 2 years of Dysthymic Disorder]: With Atypical Features (see p. 42 0] __—___..—_——————- 311 Depressive Disorder Not Otherwise Specified The Depressive Disorder Not Otherwise Specified category includes disorders with de- pressive features that do not meet the criteria for Major Depressive Disorder. Dysthy- mic Disorder. Adjustment Disorder With Depressed Mood (see p. M9). or Adjustment Disorder With Mixed Anxiety and Depressed Mood (see p. 680). Sometimes depressive symptoms can present as part of an Anxiety Disorder Not Otherwise Specified [see p. 48%). Examples of Depressive Disorder Not Otherwise Specified include 1. Premenstrual dysphoric disorder: in most menstrual cycles during the past year, symptoms {e.g., markedly depressed mood, marked anxiety, marked affective Iability. decreased interest in activitich regularly occurred during the last week of the luteal phase (and remitted within a few days of the onset ol menses}. These symptoms must be severe enough to markedly interfere Willi work. school. or usual activities and be. entirely absent for at least I week postmenses (see p. 7?1 for suggested research criteria). 2. Minor depressive disorder: episodes of at least 2 weeks of depressive symptoms but with fewer than the five items required for Major Depressive Disorder {see p. 775 for suggested research criteria]. w'l Ls 382 Mood Disorders 3. Recurrent brief depressive disorder: depressive episodes lasting from 2 days up to 2 weeks, occurring at least once a month for 12 mondts (not associath with the menstrual cycle) (see p. 73% for suggested research criteria}. 4. Post-psychotic depressive disorder of Schizophrenia: a Major Depressive Epi- sode that occurs during the residual phase of Schizophrenia [see p. 75.7 for sug— gested research criteria), 3. A Major Depressive Episode superimposed on Delusional Disorder, Psychotic Disorder Not Otherwise Specified, or the active phase of Schizophrenia. (i. Situations in which the clinician has concluded that a depressive disorder is present but is unable to determine whedier it is primary, due to a general medi- cal condition, or substance induced. Bipolar Disorders This section includes Bipolar] Disorder, Bipolar 1i Disorder, Cyclothymia, and [lipo- lar Disorder Not Otherwise Specified. There are six separate criteria sets for Bipolar I Disorder; Single Manic Episode, Most Recent Episode Hypomanic, Most Recent Epi- sode Manic, Most Recent Episode Mixed, Most Recent Episode Depressed, and Most Recent Episode Unspecified. Bipolarl Disorder, Single Manic Episode, is used to de- scribe individuals who are having a first episode of mania. The remaining, criteria sets are used to specify the nature of the current {or most recent) episode in individuals who have had recurrent mood episodes. Bipolar l Disorder Diagnostic Features The essential feature of Bipotar I Disorder is a clinical course that is characterized by the occurrence of one or more Manic Episodes {see 11). 357i or Mixed Episodes (see p. 362}. Often individuals have also had one or more Major Depressive Episodes {see p. 349). Episodes of Substance-Induced Mood Disorder (due to the direct effects of a medication. other somatic treatments for depression, a drug of abuse, or toxin ex— pOsure] or of Mmd Disorder Due. to a General Medical Condition do not count In, ward a diagnosis of Bipolar I Disorder. in addition, the episodes are not better accounted for by fichizoaffective Disorder and are not superimposed on Schizophre- nia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Oth- erwise Specified. Bipolar I Disorder ls subclasslfied in the fourth digit of the code according to whether the individual is experiencing a first episode tie, Single Manic Episod e} or whether the disorder is recurrent. Recurrence is indicated by either a shift in the polarity of the episode or an interval between episodes of at least 2 months without manic symptoms. A shift in polarity is defined as a clinical course in which a Major Depressive Episode evolves into a Manic Episode or a Mixed Episode or in which a Manic Episode or a Mixed Episode evolves into a Major Depressive Episode. In contrast, a I-[ypomanic Episode that evolves intoa Manic Episode or a Mixed Epi- gipolar | Disorder Sade, or a Manic Episode that evolves into a Mixed Episode (or vice versa), is consid- ered to he only a single episode. For recurrent Bipolar l Disorders, the nature of the current (or most recent} episode can be specified (Most Recent Episode Hypomanic, Most Recent Episode Manicr Most Recent Episode Mixed, Most Recent Episode De- pressed, Most Recent Episode Unspecified}. Specifiers If the full criteria are currently met for a Manic, Mixed, or Major Depressive Episode, the following specifiers may be used to describe the current clinical status of die epi- sode and to describe features of the current episode: Mild, Moderate, Severe Without Psychotic Features, Severe With Psychotic Features (see p. 414} With Catatonlc Features (see p. 417) with Postpartum Onset [see p. 422) If the full criteria are not currently met for a Manic, Mixed or Major Depressive Ep- isode, the following specifiers may be used to describe the current clinical status of the Bipolar [ Disorder and to describe features of the most recent episode: In Partial Remission, in Full Remission (see p. “4} With Catatonic Features [see p. 41?) With Postpartum Onset (see p. 422) if criteria are currently met for a Major Depressive Episode, the following may be used to describe features of the current episode (or, if criteria are not currently met but the most recent episode of Bipolar l Disorder was a Major Depressive Episode, these specifiers apply to that episode): Chronic (see 11. 4'17) With Melancholic Features {see p. 419) With Atypical Features {see p. 420] The following specifiers can be used to indicate the pattern of episodes: Longitudinal Course Specifiers [With and Without I-‘ull lnterepisode Recov- ery} {see p. 4'24) With Seasonal Pattern (applies onlyr to the pattern of Major Depressive Epi- sodes) (see p. 425] With Rapid Cycling (see p. 4271 Recording Procedures The diagnostic codes for Bipolar l Disorder are selected as follows: i. The first three digits are 296. 2. The fourth digit is 0 if there is a single Manic Episode. For recurrent episodes, the fourth digit indicates the nature of the current episode (or, if the Bipolar 1 Dis- c: all Mood Disorders Diagnostic criteria for 296.01: Bipolar I Disorder, Single Manic Episode A. Presence of onlyI one Manic Episode {see p. 362) and no past Major Depressive Epi- sodes. Note: Recurrence is defined as either a change in polarity from depression or an interval of at East 2 months wrthout manic symptoms. B. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder. Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. Speci'l'i.r if: Mixed: if symptoms meet criteria for a Mixed Episode (see p. 365! if the fuli criteria are currently met for a Manic. Mixed, or Major Depressive Episode, specify its current ciinical status andror features: Mild. Moderates Severe Without Psychotic FeaturesISevere With Psychotic Features {see p. 41.4} with Catatonic Features (see p. all?) with Postpartum Onset {see p. 422] If the full criteria are not currently.I met for a Manic. Mixed, or Maior Depressive Epi- sode. specify the current clinical status of the Bipolar I Disorder or features of the most recent episode: In Partial Remission. In Full Remission (see .3. 4M) with Catatonic Features (see p. 41?} With Postpartum Onset (see p. 422) _______________——————— Diagnostic criteria for 296.40 Bipolar I Disorder, Most Recent Episode Hypomanic A. Currently [or most recently) in a Hypomanic Episode {see p. 368}. 3. There has previoust been at least one Manic Episode (see p. 362} or Mixed Episode [see p. 365). C. The mood symptoms cause clinically significant distress or impairment in social, occu- pational. or other important areas of functioning. D. The mood episodes in Criteria Aand B are not better accounted for bySchizoaftectire Disorder and are not superimposed on Schizophrenia. Schizophreniform Disorder. Delusional Disorder. or Psychotic Disorder Not Otherwise Specified. Specify: Longitudinal Course Specifiers [with and without Interepisode Recovery} {see p. 424} with Seasonal Pattern (applies only to the pattern of Maior Depressive Episodes) (see p. 425) with Rapid Cycling (see p. 42?) ________._____———————— Bipolar I Disorder Diagnostic criteria for 296.41: Blpolar I Disorder. Most Recent Episode Manic A. Currently [or most recently! in a Manic Episode {see p. 362). B. There has previoust been at least one Major Depressive Episode {see p. 356), Manic Episode (see p. 362). or Mixed Episode (see p. 365). c, The mood episodes in Criteria A and B are not better accounted for by Schizoaffet‘rive Disorder and are not superimposed on Schizophrenia. Schizophreniform Disorder. Delusional iIZ'IEiorderf or Psychotic Disorder Not Otherwise Specified. if the lull criteria are currentlyI met for a Manic Episode, specify its current clinical status andior features: Mild. Moderate, Severe without Psychotic Features-Beware With Psychotic Features {see p. 414) with Catatonic Features (see p. 41?) With Postpartum Onset (see p. 422} If the full criteria are not currently met for a Manic Episode, specify the current clinical status of the Bipolar | Disorder andror features of the most recent Manic Episode: In Partial Remission. In Full Remission {see p. 414} With Catalonic Features {see p. 4 I 2’] With Postpartum Onset (see p. £221 Specify: Longitudinal Course Specifier‘s {with and Without lnterepisode Recovery) (see p. 424) With Seasonal Pattern [applies only to the pattern of Major Depressive Episodes} {see p. 425.1 With Rapid Cycling (see p. 42?] iii rs-h Mood Disorders Diagnostic criteria for 296.6x Bipolar I Disorder. Most Recent Episode Mixed A. Currently (or most recently] in a Mixed Episode {see p. 365). B. There has previously been at least one Major Depressive Episode {see p. 355), Manic Episode [see p. 362), or Mixed Episode (see p, 365}. C. The mood episodes in Criteria A and B are not better accounted for by Schizoai‘fec- live Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. h‘ the full criteria are currently met for a Mixed Episode. specify its current clinical status andror features: Mild. Moderate, Severe Without Psychotic FeaturesiSevere With Psychotic Features {see p. r115: With Catatonic Features {see p. 41?] With Postpartum Onset (see p. 422} If the full criteria are not currently met for a Mixed Episode. specify the current clinical status of the Bipolar I Disorder andror features of the most recent Mixed Episode: tn Partial Remission. In Fuil Remission [see p. ME] With Catatonic Features {see p. 41 1?} With Postpartum Onset (see p. 422) Specify: Longitudinal Course Specifier-s {With and Without lnteropisode Recovery) (see 1:. 42:1) with Seasonal Pattern {applies onlyto the pattern of Major Depressive Episodes} (see .0. £125} With Rapid Cycling (see p. £127} ___________.____———-——- Bipolar I Disorder Diagnostic criteria for 296.5): Bipolar I Disorder. Most Recent Episode Depressed A Currently [or most recently] in a Major Depressive Episode (see p. 356}. B. There has previously been at least one Manic Episode {see p. 362) or Mixed Episode (see p. 365]. C. The mood episodes in Criteria A and B are not better accOunted for by Schizoaffec- tive Disorder and are not superimposed on Schizophrenia, Schizophreni‘iorm Disorderj Delusionai Disorder. or Psychotic Disorder Not Otherwise Specified. if the full criteria are currently met for a Major Depressive Episode. specify its current clinical status andior features: Mild. Moderate. Severe Without Psychotic FeaturesiSevere with Psychotic Features {see p. 4123 Chronic (see p. 41?] With Catatonic Features {see p. :11?) With melancholic Features {see p. 419) with Atypical Features (see p. 420) with Postpafium Onset (see p. 422] If the full criteria are not currently met for a Major Depressive Episode, specifythe cur- rent clinical status of the Bipolar l Disorder andror teatures of the most recent Major De- pressive Episode: In Partial Remission, In Full Remission (see p. 412) Chronic [see p. 417) i with Catatonic Features (see p. 41?} ' with Melanchollc Features (see p. 419} with Atypical Features {see p. 420] with Postpartum Onset [see p. 422) i Specify: ' Longitudinal Course Specifiers (with and Without lnterepisude Recovery) {see p. 424] I with Seasonal Pattern {applies only to the pattern of Major Depressive Episodes: . (see p. 425‘; With Rapid Cycling (see p. 42?) ______________——————————— Diagnostic criteria for 296.7 Bipolar l Disorder. Most Recent Episode Unspecified AI . . . Criteria, except far duration, are currently (or most recently] met for a Manic fse E p. 362], a Hypomanic {see . 368 a M' ' {me p‘ 356]— p ]. ixed {see p. 365]. or a Meier Depressive Episode B. There has previously been at lea ' ' (see pl 365). st one Manic Episode {see p. 362] or Mixed Episode C. “113 !1 00d symptoms cause c 'n' ' ' ' n r r m r n n at a ll 103"}! Signl‘llta tdist OS I I - - Oicii _ I S 0 l pal mt: t I national. or other important areas of unclionir g. S F I. D_ . . . :3: Fgum:si.rnii:i|:[oi'ris In Criteria A and B are not better accounted for by Schizoaf‘fec isor er an are not superimposed 0'1 Schizo ' ' ' - I I I . phrenia, Schizo hreni ' Delusional Disorder. or Psychotic Disorder Not Otherwise Speciffecl I am Disorder' E. Th ' I ' e. mood symptoms in Criteria A and B are not due to the direct physiological effects of a substance to g a drug of abuse ‘ ' _ - a . a medication, or th medical condition (9.9., hyperthyroidism]. D er treatment} or a general Specify: Longitudinal Course S cifie ' . - _ {see pl 424} M '5 ITmml‘l and Without lnterepisode Recovery} with Seasonal Pattern a lie ' {SEE F1425} ( pp 5 only to the pattern of Major Depressive Episodes) with Rapid Cycling (see p. 42?} ——-—-—.—_.___—____ 296.89_ Bipolar II Disorder (Recurrent Major Depressive Episodes With Hypomanic Episodes) Diagnouic Features The ._ _ . . . [he Uiieprt‘ial feaFure of Bipolar ll Disorder IS a clinical course that is characterimd by ‘nce 0 one or more Major Deprecqivc- E ' - t ' ' I I a by at 16‘“! one Hv I I \ _ .. prism :25 [Criterion A) accompanied _ . , pomeiirc Episodeii riteriori B) H i \orr ' ' ‘ ‘ I . . arm F. isodes 'h ld confused with the several da ' H 1 P b nu n01 be . ysofcuthymn that ma ' ' ' I _ _ _ - y follow remissiion ofa Ma or D“- Elrcgsivf [flair—afar. The presence of a Manic or Mixch Episode preclude“; the dial' nos-ls 1ch air isorder (Criterion C) E " ‘ ' ' I - S I . pisodes of Substance—hum d VI d ' ' ' (due to the direct physiolo ' ' CC I w Dbordcr . _ gical effects of a medication othc ' ' d a s I ‘ _ _ . , r somatic treatments for h:p;::~ll:1, d; irgs 0;.1busc.orloxm exposure) or of Mood Disorder Due to a General :3 i on ition 0 not count toward '1 dia ' ' I I I . ghosts of Bipotar ll 01' cl- ' ' h i _ I sor cr. In add:- 1 the cpisodes must not be better accounted for by Schizoaffective Disorder and .Cmiiiot superii;1pose3 on Schizophrenia, Scliizopl-Lreniform Disorder Delusional Dir. er, or 55% totic isorder Not Otherwise S " ' " ' ' r ‘- I I . pacified (Li-iterio-i DJ The 's‘ m I n I ‘ I ‘I I I . . .ymrtoms ust cause ciinically significant distress- or rm pairmcnt in social, occu pationhl ctr nih- Mood Disflrders 296.89 Bipolar ll Disorder (Recurrent Major Depressive Episodes with Hypomanic Episodes) nlng (Criterion E}. In some cases, the Hyponianic Epi- e. impairment. instead. [he impairment may result front from n chronic pattern of unpredictable inoocl cpl- sndes and fluctuating unreliable interpersonal or occupational functioning Individuals with Bipolar ll Disorder may not View the I-lypomanic Episodes as pathological. although others may be troubled by the individual’s erratic behavior. Often individuals. pari—iculariy when in the midst of a Major Depressive Episode, do not recall periods of hypomania without reminders. from close friends or relatives. information from other informants is often critical in c-slablishing the diagnosis of Bipolar ll Disorder. er important areas of functio sodes themselves do not caus the Major Depressive Episodes or Specifiers The following specifiers for Bipolar I[ Disorder should he used to indicate the nature of the current episode or. if the full criteria are not currentty met for a Hypomanic 01' Major Depressive Episode, the nature of the most recent episode: Hypomnnic. This specifier is used if the current [or most recent] episode is a Hypomanic Episode. Depressed. This speci a Major Depressive Episode. list is used if the current (or most recent] episode is If the full criteria are currently met for a Major Depressive Episode, the following specifiers may be used to describe the current clinical status of the episode and to de- scribe features of the current episode; Mild, Moderate, Severe Without Psychotic Features. Severe With Psychotic Features [see p. 412] Chronic (see p. 417] With Catatonic Features (see p. 4L7} With Melancholic Features (see p. 419} With Atypical Features [SEE p. 420] With Postpartum Onset {see p. 422) [f the full criteria are iiotcurrently met for a Hypomanic or Major Depressive Epi- sode. the followng specifiers may he used to describe the current clinical status of the Bipolar ll Disorder and to describe features of the most recent Major Depressive Ep- isode (only if it is the most recent type of mood episode]: in Partial Remission, In Full Remission [see p. 412} Chronic (see p. 417] With Catatonic Features {see p. 41'?) with Melancholic Features {see p. 419) With Atypical Features (see. p. 420} With i’nstparluin Onset {see p. 422] The following specifiers may be used to indicate the pattern or frequency of epi- sodas: ..Nmm.mm mmuommq : Unmoamw 325:,an Emmow Umqummgm mEMOQmm in: Encaman mummaammv www nuuvfluxln. gig??? wlxjillrfi zilk.J.,.sk.€l_z..§ 21......fiuuzfiz,sisfifififlknfluénfirfifirrfifififivaha¥ai§sl (akfimfiwvxv; {uglflfiérgfa ,fi§.§fz2 6.9933»? 233.9 «ox www.mw 2.3.9.. = 63033 >. 36338 A2 3595 9“ 02m cm 308 3mm? 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DSM%20Mood%20Disorders%20reading - DIAGNOSTIC AND...

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