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Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
Mood disorder
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Mood disorder
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Mood disorder

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  • 1. Mood Disorders Presented by Erica Vassell
  • 2. Statistics As per the DSM-IV TR, 15% of people diagnosised with Major Depressive Disorder or Bipolar Disorder commit suicide Suicide is the 10th leading cause of death in the United States as per National Institue of Mental Health http://www.nimh.nih.gov
  • 3. Mood Disorders Depressive Disorders Major Depressive Disorder Dysthymic Disorder Depressive Disorder NOS Bipolar Disorders Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder Bipolar NOS Other Mood Disorders Mood Disorder Due to General Medical Condition Substance-Induced Mood Disorder Mood Disorder NOS
  • 4. • Depressed mood or a loss of interest or pleasure in daily activities for more than two weeks. • Mood represents a change from the person's baseline. • Impaired function: social, occupational, educational. • Specific symptoms, at least 5 of these 9, present nearly every day: 1.Depressed mood or irritable most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). 2. Decreased interest or pleasure in most activities, most of each day 3. Significant weight change (5%) or change in appetite 4. Change in sleep: Insomnia or hypersomnia 5. Change in activity: Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Guilt/worthlessness: Feelings of worthlessness or excessive or inappropriate guilt 8. Concentration: diminished ability to think or concentrate, or more indecisiveness 9. Suicidality: Thoughts of death or suicide, or has suicide plan DSM-IV Criteria for Major Depressive Disorder (MDD) 296.XX
  • 5. Single vs. Recurrent Major depressive disorder, single episode criterion: Presence of a single major depressive episode. The major depressive 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. There has never been a manic episode, a mixed episode, or a hypomanic episode. Major depressive disorder, recurrent criterion: Presence of two or more major depressive episodes (each separated by at least 2 months in which criteria are not met for a major depressive episode.) The major depressive episodes are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified. There has never been a manic episode, a mixed episode, or a hypomanic episode.
  • 6. Specified Clinical Status Mild, moderate, severe without psychotic features/severe with psychotic features Chronic Catatonic Features Melancholic features Atypical features Postpartum onset
  • 7. Prevalence 15% of those diagnosed with MDD commit suicide MDD is twice as common in adolescent and adult female compared to their male counterparts MDD may begin at any age but has an average onset in the mid- 20’s Evidence suggests that MDD has a inherited component
  • 8. Differential Diagnosis Manic, Mixed or Hypomanic episode Mood Disorder Due to General Medical Condition Substance-Induced Mood Disorder Dysthymic Disorder Schizoaffective Disorder
  • 9. Background: 300.4 Dysthymic Disorder Essential feature: Chronically depressed mood for most of the day, more days than not, for at least 2 years. Children or adolescents may be irritable rather than depressed The required minimum here is 1 year Additional Symptoms: Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or difficulty making decisions Feelings of hopelessness American Psychiatric Association. (2000). Dysthymic Disorder. Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  • 10. Associated Features and Disorders: 300.4 Dysthymic Disorder Within 5 years, up to 75% of individuals with Dysthymic Disorder will develop Major Depressive Disorder Dysthymic Disorder may be associated with Borderline, Histrionic, Narcissistic, Avoidant, and Dependent Personality Disorders Note: Assessment of features of a Personality Disorder is difficult because chronic mood symptoms may contribute to interpersonal problems or be associated with distorted self-perception American Psychiatric Association. (2000). Dysthymic Disorder. Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Associated features of Dysthymic Disorder are similar for a Major Depressive Episode: Feelings of inadequacy Social Withdrawal Generalized loss of interest or pleasure Feelings of guilt or brooding about the past Decreased activity effectiveness, or productivity Subjective feelings of irritability or excessive anger Vegetative symptoms (sleep, appetite, weight change, and psychomotor) less common
  • 11. Differential Diagnosis: 300.4 Dysthymic Disorder Major Depressive Disorder and Dysthymic Disorder share similar symptoms Dysthymic Disorder is chronic with less severe depressive symptoms Can last for many years so mood disturbance can be considered person’s “usual” functioning Distinguish a Mood Disorder Due to a General Medical Condition, with Depressive Feature from Dysthymic Disorder using history, laboratory findings, or physical examination A Substance-Induced Mood Disorder can be distinguished from Dysthymic Disorder by the fact that a substance (e.g., a drug of abuse, etc.) is judged to be related to mood disturbance Coexisting personality disorders can exist This is why it is important to ensure you use the criteria very carefully when making a diagnosis Always look for impairment of function  American Psychiatric Association. (2000). Dysthymic Disorder. Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  • 12. 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: in children and adolescents, mood can be irritable and duration must be at least 1 year). B. Presence, while depressed, of two (or more) of the following: 1) Poor appetite or overeating 2) Insomnia or hypersomnia 3) Low energy or fatigue 4) Low self-esteem 5) Poor concentration or difficulty making decisions 6) Feelings of hopelessness C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time. American Psychiatric Association. (2000). Dysthymic Disorder. Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  • 13. Diagnostic Criteria for 300.4 Dysthymic Disorder (continued) D. No Major Depressive Episode (see the Criteria p. 356) has been present during the first 2 years of the disturbance (1 year for children or adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, in Partial Remission. (Note: There may have been a previous Major Depressive Disorder Depressive Episode provided there was a full remission (no significant signs or symptoms for 2 months) before developing of the Dysthymic Disorder. In addition, after the initial 2 years [1 year in children or adolescents) of Dysthymic Disorder, there may be superimposed episodes of Major Depressive Disorder, in which case both diagnoses may be given when the criteria are met for a Major Depressive Episode. E. There has never been a Manic Episode (see the Criteria p. 362), a Mixed Episode (see the Criteria p. 365), or a Hypomanic Episode (see the Criteria p. 368), and criteria have never been met for Cyclothymic Disorder. American Psychiatric Association. (2000). Dysthymic Disorder. Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  • 14. Diagnostic Criteria for 300.4 Dysthymic Disorder (continued) F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder. G. 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 (e.g., hypothyroidism). H. The symptoms cause clinically significant distress or impairment in social, occupational, 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 older Specify (for most recent 2 years of Dysthymic Disorder): With Atypical Features (see p. 420) American Psychiatric Association. (2000). Dysthymic Disorder. Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  • 15. Assessment for 300.4 Dysthymic Disorder Assessment: Using the DSM-IV-TR diagnostic criteria and the multiaxial assessment Noting comorbidity issues as Dysthymic Disorder is characteristically associated with high frequencies of psychiatric comorbidity. Assessment can be difficult as there is no “pure form” of Dysthymic Disorder. Difficulties when diagnosing include: Sansone R.A. & Sansone L.A. (2009). Dysthymic Disorder: Forlorn and Overlooked? Psychiatry (Edgmont). 6(5): 46– 51. Soft mood symptoms Comorbidities can be distracting Lack of patient recognition in early-onset Misdiagnosis of symptoms
  • 16. Depressive Disorder NOS (311) The Depressive disorder NOS category includes disorders with depressive features that do not meet the criteria for Major Depressive Disorder, Dysthymic disorder, Adjustment Disorder with Depressed Mood or Adjustment Disorder with Mixed Anxiety and Depressed Mood. Sometimes depressive symptoms can present as part of an Anxiety Disorder Not otherwise Specified. Examples of Depressive Disorder Not Otherwise Specified include. Premenstrual Dysphoric Disorder: in most menstrual cycles during the past years, (e.g., markedly depressed mood, marked anxiety, marked affective lability, or decreased interest in activities) regularly occurred during the onset of menses. These symptoms must be severe enough to markedly interfere with work, school, or usual activities and be entirely absent for at least 1 week post menses. Minor depressive disorder: episodes of at at least 2 weeks of depressive symptoms but with fewer than the five items required for Major Depressive Disorder. Recurrent brief depressive disorder: depressive episodes lasting from 2 days up to 2 weeks, occurring at least once a month for 12 months(not associated with the menstrual cycle) Post psychotic depressive Disorder of schizophrenia: a Major Depressive Episode that occurs during the residual phase of schizophrenia A Major Depressive Episode superimposed on delusional disorder, Psychotic Disorder Not Otherwise Specified, or the active phase of schizophrenia. Situations in which the clinician has concluded that a depressive disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced.
  • 17. Bipolar I Disorder Bipolar I Disorder is a chronic illness characterized by manic or rapid cycling episodes of mania and depression Rapid cycling occurs when the individual has four or more episodes of major depression, mania, and/or mixed episode within one year
  • 18. Signs & Symptoms Manic Phase Euphoria Inflated self-esteem Poor judgment Rapid speech Racing thoughts Aggressive behavior Agitation or irritation Increased physical activity Risky behavior Spending sprees Increased drive to perform or achieve goals Increased sex drive Decreased need for sleep Easily distracted Careless or dangerous use of drugs or alcohol Delusions or a break from reality (psychosis) AND impairment in functioning which may result in: Frequent absences from work or school Poor performance at work or school Impaired social relationships
  • 19. Signs & Symptoms Depressive Phase Suicidal thoughts or behavior- up to 15% of people commit suicide Sadness Hopelessness Anxiety Guilt Sleep problems Low appetite or increased appetite Loss of interest in activities once considered enjoyable (anhedonia) Fatigue Problems concentrating Irritability Chronic pain without a known cause Once again these symptoms may cause impairment of functioning resulting in: Frequent absences from work or school Poor performance at work or school
  • 20. Prevalence/Risk Factors  Bipolar I Disorder occurs in about 1% of the population  Age of onset is usually in the early 20’s  Men and women are equally affected by bipolar disorder, however rapid cycling occurs more often in women.  Women also tend to experience more depressive and mixed state episodes than men  Individuals with a parent or sibling suffering from Bipolar I Disorder have a greater risk of developing the disorder
  • 21. Comorbidity/Differential Diagnosis Other conditions that commonly occur with Bipolar I Disorder include : Attention Deficit Hyperactivity Disorder (ADHD), Conduct Disorder, Antisocial Personality Disorder, Borderline Personality Disorder, Anxiety Disorders , and Substance Use Disorders. Physical health problems are also common. In order to make an accurate diagnosis, Bipolar I Disorder must also be distinguished from:  Mood Disorder Due to a General Medical Condition  Substance-Induced Mood Disorder  Other Mood Disorders (Major Depressive Disorder, Dysthymia, Bipolar II Disorder, Cyclothymic Disorder)  Schizophrenia, Schizoaffective Disorder, and Other Psychotic Disorders
  • 22. Diagnosis of Bipolar Disorder requires at least one Manic or Mixed episode, but there may be episodes of Hypomania or Major Depression as well Subtypes for Bipolar I Disorder: Bipolar I Disorder Single Manic Episode Bipolar I Disorder Most Recent Episode Hypomanic Bipolar I Disorder Most Recent Episode Manic Bipolar I Disorder Most Recent Episode Mixed Bipolar I Disorder Most Recent Episode Depressed Bipolar I Disorder Most Recent Episode Unspecified
  • 23. Diagnostic Criteria for 296.0x Bipolar I Disorder, Single Manic Episode A. Presence of only one Manic Episode and no past Major Depressive Episodes. 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. Specify if:  Mixed: if symptoms meet criteria for a Mixed Episode Specify (for current or most recent episode):  Severity/Psychotic/Remission Specifiers With Catatonic Features With Postpartum Onset
  • 24. Diagnostic Criteria for 296.40 Bipolar I Disorder, Most Recent Episode Hypomanic A. Currently (or most recently) in a Hypomanic Episode B. There has previously been at least one Manic Episode or Mixed Episode C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. Specify:  Longitudinal Course Specifiers (With and Without Interepisode Recovery)  With Seasonal Pattern  With Rapid Cycling
  • 25. Diagnostic Criteria for 296.6x Bipolar I Disorder, Most Recent Episode Mixed A. Currently (or most recently) in a Mixed Episode B. There has previously been at least one Major Depressive Episode, Manic Episode, or Mixed Episode C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. Specify (for current or most recent episode):  Severity/Psychotic/Remission Specifiers With Catatonic Features With Postpartum Onset Specify:  Longitudinal Course Specifiers (With and Without Interepisode Recovery) With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) With Rapid Cycling
  • 26. Diagnostic Criteria for 296.4x Bipolar I Disorder, Most Recent Episode Manic A. Currently (or most recently) in a Manic Episode B. There has previously been at least one Major Depressive Episode ,Manic Episode, or Mixed Episode C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. Specify (for current or most recent episode):  Severity/Psychotic/Remission Specifiers With Catatonic Features With Postpartum Onset Specify:  Longitudinal Course Specifiers (With and Without Interepisode Recovery) With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) With Rapid Cycling
  • 27. Diagnostic Criteria for 296.5x Bipolar I Disorder, Most Recent Episode Depressed A. Currently (or most recently) in a Major depressive Episode B. There has previously been at least one Manic Episode or Mixed Episode C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. Specify (for current or most recent episode):  Severity/Psychotic/Remission Specifiers Chronic With Catatonic Features With Melancholic Features With Atypical Features With Postpartum Onset Specify:  Longitudinal Course Specifiers (With and Without Interepisode Recovery) With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) With Rapid Cycling
  • 28. Diagnostic Criteria for 296.7 Bipolar I Disorder, Most Recent Episode Unspecified A. Criteria, except for duration, are currently (or most recently) met for a Manic, a Hypomanic, a Mixed, or a Major Depressive Episode B. There has previously been at least on Manic Episode or Mixed Episode C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. E. The mood symptoms in Criteria A and B are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). Specify:  Longitudinal Course Specifiers (With and Without Interepisode Recovery) With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) With Rapid Cycling
  • 29. Bipolar II Disorder Bipolar II is similar to Bipolar I Disorder, with moods cycling between high and low over time. However, in Bipolar II disorder, the “high” moods are less severe and are referred to as hypomanic episodes, or hypomania. • Bipolar II Disorder is distinguished from Bipolar I Disorder by the presence of one or more manic or mixed episode • If an individual previously diagnosed with Bipolar II Disorder develops a manic or mixed episode, the diagnosis is changed to Bipolar I Disorder • Individuals with Bipolar II Disorder have had at least one hypomanic episode in life • Most people with bipolar II disorder also experience depressive episodes
  • 30. Signs & Symptoms During a hypomanic episode, elevated mood can manifest itself as either euphoria (feeling "high") or as irritability Symptoms during hypomanic episodes include:  Flying suddenly from one idea to the next  Rapid, "pressured," and loud speech  Increased energy, with hyperactivity and a decreased need for sleep While these symptoms may be observable to others, they do NOT cause the individual significant impairment in social or occupational areas of functioning
  • 31. Prevalence/Risk Factors Bipolar II Disorder occurs in about .5% of the population and is diagnosed more in women Similarly to Bipolar I, age of onset is in the early 20’s Individuals with an immediate family member are at greater risk
  • 32. Comorbidity/Differential Diagnosis Other conditions that commonly occur with Bipolar I Disorder include: ADHD, Substance Use Disorder, and Anxiety Disorders In order to make an accurate diagnosis, Bipolar II Disorder should also be distinguished from:  Mood Disorder Due to a General Medical Condition  Substance-Induced Mood Disorder  Major Depressive Disorder  Bipolar I Disorder  Cyclothymic Disorder  Psychotic Disorders
  • 33. Diagnostic Criteria for 296.89 Bipolar II Disorder A. Presence (or history) of one or more Major Depressive Episodes. B. Presence (or history) of at least one Hypomanic Episode. C. There has never been a Manic Episode or a Mixed Episode. D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify current or most recent episode:  Hypomanic: if currently (or most recently) in a Hypomanic Episode Depressed: if currently (or most recently) in a Major Depressive Episode Specify (for current or most recent Major Depressive Episode only if it is the most recent type of mood episode):  Severity/Psychotic Remission Specifiers  Chronic  With Catatonic Features With Melancholic Features With Atypical Features With Postpartum Onset Specify:  Longitudinal Course Specifiers (With and Without Interepisode Recovery) With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) With Rapid Cycling
  • 34. Cyclothymic Disorder Cyclothymic Disorder is a chronic, fluctuating mood disturbance involving numerous periods of hypomanic symptoms and numerous periods of depressive symptoms. It is a mild form of bipolar disorder in which a person has mood swings over a period of years that go from mild depression to euphoria (joy) and excitement.
  • 35. Signs & Symptoms Episodes of Hypomania occur for at least 2 years. Mood swings are less severe than in Bipolar Disorder, Major Depression and Manic. Symptoms are persistent, with no more than 2 symptom free months in a row. During a “high“ mood, the person may feel very optimistic (hopeful) and cheerful. During a “low“ mood the person has symptoms similar to depression. Feeling sad and hopeless, losing interest.
  • 36. Prevalence Cyclothymic disorder usually begins in adolescence or early adulthood. The onset is usually insidious and runs a chronic course. It appears equally in men and in women but women are more likely to present for treatment than men. Studies have reported a lifetime prevalence from 0.4% to 1%. Prevalence in mood disorders clinics may range from 3% to 5%.
  • 37. Causes The causes are unknown. It must be distinguished from a mood disorder due to a general medical condition. Cyclothymic disorder maybe more common in the first degree biological relatives of individuals with Bipolar I Disorder. People with this disorder usually have a family history of depression, bipolar disorder, suicide, alcohol or drug dependence. There is a 15%-50% chance that the person will subsequently develop Bipolar I or II Disorder.
  • 38. Diagnostic criteria for 301.13 Cyclothymic Disorder A. For at least 2 years, the presence of numerous periods with hypomanic symptoms (i.e. poor judgment, rapid speech, racing thoughts, agitation, inability to concentrate) and numerous periods with depressive symptoms that do not meet criteria for Major Depressive Episodes. Note: In children and adolescents the duration must be at least 1 year. B. During the above 2- year period( 1 year in children and adolescent), the person has not been without the symptoms in criteria for more than 2 months at a time. C. No Major Depressive Episodes ( i.e. feels sad or empty, significant weight loss, recurrent thoughts of death/ suicide with a plan), Manic episodes (i.e. grandiosity, decrease need for sleep, distractibility), or Mixed episodes (criteria for major depressive and manic episodes) has been present during the first 2 years of the disturbance.
  • 39. Diagnostic criteria for 301.13 Cyclothymic Disorder Note: After the initial 2 years (1 year in children and adolescents) of Cyclothymic Disorder, there may be superimposed Manic or Mixed Episodes ( in which case both Bipolar I Disorder and Cyclothymic Disorder may be diagnosed) or Major Depressive Episodes ( in which case both Bipolar II Disorder and Cyclothymic Disorder may be diagnosed). D. The symptoms in the Criterion A are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. E. The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or general medical condition (e.g., hyperthyroidism). F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • 40. Bipolar NOS This category includes disorders with bipolar features that do not meet criteria for any specific Bipolar Disorder. Very rapid alternation over days between manic symptoms and depressive symptoms that meet symptom threshold criteria but not minimal duration criteria for Manic, Hypomanic, or Major Depressive Episodes. Recurrent Hypomanic Episodes without intercurrent depressive symptoms A Manic or Mixed Episodes superimposed on Delusional Disorder, residual Schizophrenia, or Psychotic Disorder Not Otherwise Specified Hypomanic Episodes, along with chronic depressive symptoms, that are too infrequent to qualify for a diagnosis of Cyclthoymic Disorder. Situations in which the clinician has concluded that a Bipolar Disorder is present but is unable to determine weather its primary, due to a general medical condition or substance induced
  • 41. Background: 293.83 Mood Disorder Due to General Medical Condition Essential feature: Prominent and persistent disturbance in mood due to the direct physiological effects of a general medical condition May involve depressed mood, markedly diminished interest or pleasure; or elevated, expansive, or irritable mood A variety of general medical condition may cause mood symptoms American Psychiatric Association. (2000). Mood Disorder Due to a General Medical Condition Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Degenerative conditions •Parkinson’s Disease Viral or other infections •Hepatitis Cerebrovascular disease •Stroke Metabolic conditions • Vitamin B12 deficiency Endocrine conditions •Hyper- & hypothyroidism Autoimmune conditions •Lupus Certain cancers •Carcinoma of the pancreas
  • 42. Subtypes and Recording: 293.83 Mood Disorder Due to General Medical Condition One of the following subtypes may be used to indicate which of the following symptom predominates: With Depressive Features With Major Depressive-Like Episode With Manic Features When recording diagnosis, clinicians should note Specific phenomenology of the disturbance, including appropriate subtype Identified general medical condition judged to be causing the disturbance American Psychiatric Association. (2000). Mood Disorder Due to a General Medical Condition Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  • 43. Differential Diagnosis:293.83 Mood Disorder Due to General Medical Condition A separate diagnosis of Mood Disorder Due to a General Medical Condition is not given if the depressive symptoms develop exclusively during the course of Vascular Dementia A delirium If there is evidence of substance use, withdrawal, exposure to a toxin (a Substance-Induced Mood Disorder should be considered) Diagnosis can be given in addition to a diagnosis of dementia Clinicians need to distinguish this disorder from Major Depressive Disorder, Bipolar I & Bipolar II Disorders, and Adjustment Disorder with Depressed Mood Mood Disorder Not Otherwise Specified may be used if clinician cannot determine cause American Psychiatric Association. (2000). Mood Disorder Due to a General Medical Condition Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  • 44. Diagnostic Criteria for 293.83 Mood Disorder Due to General Medical Condition A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following: 1) Depressed mood or markedly diminished interest or pleasure in all, or almost all, activities 2) Elevated, expansive, or irritable mood B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. C. The disturbance is not better accounted for by another mental disorder (e.g., Adjustment Disorder with Depressed Mood in response to the stress of having a general medical condition). D. The disturbance does not occur exclusively during the course of a delirium. E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. American Psychiatric Association. (2000). Mood Disorder Due to a General Medical Condition Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  • 45. Diagnostic Criteria for 293.83 Mood Disorder Due to General Medical Condition (continued) Specify type: With Depressive Features: if the predominant mood is depressed by the full criteria are not met for a Major Depressive Episode. With Major Depressive-Like Episode: if the full criteria are met (except Criteria D) for a Major Depressive Episode (see Criteria on p. 356) With Manic Features: if the predominant mood is elevated, euphoric, or irritable With Mixed Features: if the symptoms of both mania and depression are present but neither predominates Coding note: Include the name of the general medical condition on Axis I, e.g., 293.83 Mood Disorder due to Hypothyroidism, With Depressive Features; also code the general medication condition on Axis III (see Appendix G for the codes). Coding note: If depressive symptoms occur as part of a preexisting Vascular Dementia, indicate the depressive symptoms by coding the appropriate subtype, i.e., 290.43 Vascular Dementia, With Depressed Mood
  • 46. Assessment for 293.83 Mood Disorder Due to General Medical Condition Assessment: Using the DSM-IV-TR diagnostic criteria and the multiaxial assessment A careful and comprehensive assessment of multiple factors is necessary for diagnosis Laboratory findings, history, and a physical examination can help make the determination Other mood disorders must be ruled out American Psychiatric Association. (2000). Mood Disorder Due to a General Medical Condition Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author Sue, D., Sue, D.W., & Sue, S. (2010). Understanding abnormal behavior (9th ed.). Boston, MA: Wadsworth.
  • 47. Background: Substance-Induced Mood Disorder Substance-Induced Mood Disorder is diagnosed when the clinician believes a drug or other chemical substance or Withdrawal from a drug causes symptoms suggestive of a Manic, Mixed, Hyopmanic, or Major Depressive episode It is defined in DSM-IV-TR as “a prominent and persistent disturbance of mood . . . that is judged to be due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or somatic treatment for depression, or toxin exposure)” (APA, 2000, p. 405). The mood can manifest as manic (expansive, grandiose, irritable), depressed, or a mixture of mania and depression.
  • 48. Associated Features and Disorders: Substance-Induced Mood Disorder Manic Symptoms in Substance Induced Mood Disorder • Elation • Confidence • Delusional thinking • High level of energy • Loud and rapid speech • Racing thoughts • Impulsive behavior • Overeating • Fast and reckless driving • Engaging in wild business schemes Depressive Symptoms in Substance Induced Mood Disorder • Loss of interest and pleasure • Irritability and anger • Changes in appetite • Sleep problems • Fatigue • Slow movement and thinking • Feelings of worthlessness and guilt
  • 49. Associated Features and Disorders: Substance-Induced Mood Disorder One of the following subtypes may be used to indicate which of the following symptom presentation predominates: With Depressive Features: if the predominant mood is depressed With Manic Features: if the predominant mood is elevated, euphoric, or irritable With Mixed Features: if symptoms of both mania and depression are present and neither predominates The context of the development of the mood symptoms may be indicated by using one of the following specifiers: With Onset During Intoxication: if the criteria are met for Intoxication with the substance and the symptoms develop during the intoxication syndrome With Onset During Withdrawal: if criteria are met for Withdrawal from the substance and the symptoms develop during, or shortly after, a withdrawal syndrome American Psychiatric Association. (2000). Substance-induced Mood Disorder. Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  • 50. Differential Diagnosis: Substance-Induced Mood Disorder Remember that a substance is judged to be the cause of symptoms, this is untrue with another mood disorder diagnosis. Keep in mind that Mood symptoms occur commonly in Substance Intoxication and Substance Withdrawal Example: dysphoric mood is a characteristic feature of Cocaine Withdrawal. Cocaine- Induced Mood Disorder should be diagnosed instead of Cocaine Withdrawal only if the mood disturbance is substantially more intense than what is usually encountered with Cocaine Withdrawal and is sufficiently severe to be a separate focus of attention and treatment. Substance-induced mood symptoms occurring during delirium are considered to be an associated feature of the delirium and are not diagnosed separately Consider Mood Disorder Due to a General Medical Condition when there is a possibility that the mood symptoms are caused by physiological consequences of general medical conditions rather than the medication, however these disorders can coexist. Depressive Disorder Not Otherwise Specified or Bipolar Disorder Not Otherwise Specified would be indicated when there is insufficient evidence to determine whether the mood symptoms are due to a substance or general medical condition
  • 51. Diagnostic Criteria for Substance-Induced Mood Disorder A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following: (1) depressed mood markedly diminished interest or pleasure in all, or almost all, activities (2) elevated, expansive, or irritable mood B. B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2): (1) the symptoms in Criterion A developed during, or within 1 month of, Substance Intoxication or Withdrawal (2) medication use is etiologically related to the disturbance C. The disturbance is not better accounted for by a Mood Disorder that is not substance induced. Evidence that the symptoms are better accounted for by a Mood Disorder that is not substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance-induced Mood Disorder (e.g., a history of recurrent Major Depressive Episodes).
  • 52. Diagnostic Criteria for Substance- Induced Mood Disorder (continued) D. The disturbance does not occur exclusively during the course of a delirium. E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the mood symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention. Diagnosis should include Code [Specific Substance]-Induced Mood Disorder: (291.8 Alcohol; 292.84 Amphetamine [or Amphetamine-Like Substance]; 292.84 Cocaine; 292.84 Hallucinogen; 292.84 Inhalant; 292.84 Opioid; 292.84 Phencyclidine [or Phencyclidine-Like Substance]; 292.84 Sedative, Hypnotic, or Anxiolytic; 292.84 Other [or Unknown] Substance) Specify Subtypes and Specifiers American Psychiatric Association. (2000). Substance-Induced Mood Disorder. Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  • 53. Background: 296.90 Mood Disorder Not Otherwise Specified The Diagnostic and Statistical Manual of Mental Disorders (DSM- IV) explains mood disorder not otherwise specified (NOS) as a mood disorder that impairs an individual but does not meet each criterion required for the diagnosis of a specific mood disorder. In other words, it's a disabling illness affecting moods that does not meet the specification for other affective disorders BUT it is considered significant enough for it to be defined as an illness. American Psychiatric Association. (2000). Mood Disorder Not Otherwise Specified Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  • 54. Associated Features and Disorders: 296.90 Mood Disorder Not Otherwise Specified Subtypes and Modifiers Various diagnostic specifiers can be applied to specific subtypes of mood disorders. These have prognostic and treatment implications and may prove to have etiologic implications. Melancholic: Melancholic depression is a severe form of depression associated with guilt, remorse, loss of pleasure, and extreme vegetative symptoms. Postpartum: Postpartum depression occurs within 4 weeks of delivery. The presence of one episode of postpartum mood disorder is strongly predictive of a recurrence. Seasonal: Seasonal mood disorders show a consistent seasonal pattern of variation. The most common pattern is a worsening of depression during the fall and winter with improvement in the spring. The reverse is sometimes true. If the depression is a component of a bipolar disorder, the manic and hypomanic episodes may show a seasonal association. Atypical: Atypical depressions show a pattern of hypersomnia, increased appetite or weight gain, mood reactivity, long-standing rejection sensitivity, anergia, and leaden paralysis. Rapid Cycling: Patients with bipolar disorder may have frequent (rapid) cycles. To meet criteria for rapid cycling, four mood disturbances per year must be present. The suicide rate may be higher than in non-rapid cyclers. Catatonic: The catatonic specifier is applied to mood disorders when there are pronounced movement abnormalities, including motoric immobility or excessive purposeless motor activity, maintenance of a rigid posture, mutism, stereotyped movement, echolalia (repetition of a word or phrase just spoken by another person), or echopraxia (repetition of movements made by another person). American Psychiatric Association. (2000). Mood Disorder Not Otherwise Specified Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  • 55. Treatment A mixture of Pharmacotherapy and Psychotherapy Psychotherapy—A number of psychotherapies have been advocated including cognitive behavioral therapy, interpersonal psychotherapy, group therapy, and problem- solving therapy, Motivational interviewing Pharmacotherapy—antidepressants or mood stabilizers are typically are given Support groups- Community based, AA, NA
  • 56. Common Medications Used Unipolar Selective serotonin reuptake inhibitors (SSRIs) Prozac, Zoloft, Paxil, Celexa, Lexapro Serotonin and norepinephrine reuptake inhibitors (SNRIs) Cymbalta, Effexor XR, Pristiq Norepinephrine and dopamine reuptake inhibitors (NDRIs) Wellbutrin Atypical antidepressants Oleptro, Remeron, Vibryd Tricyclic antidepressants Monoamine oxidase inhibitors (MAOIs) Parnate, Nardil, Emsam Other medication strategies A doctor may choose other drugs that are not necessarily considered antidepressants Bipolar Mood Stabilizers Lithium Anticonvulsants Depakote Antidepressants Antipsychotic Zyprexa, Abilify, Risperdal, Geodon, Clorazil Benzodiazpines

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