During a dysphoric manic episode the patient experiences mania and

CHAPTER 3

Mood Disorders

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

Quick Guide to the Mood Disorders

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

Mood Episodes

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

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

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

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

Mood Disorders

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

DEPRESSIVE DISORDERS

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

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

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

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

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

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

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

BIPOLAR AND RELATED DISORDERS

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

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

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

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

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

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

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

Other Causes of Depressive and Manic Symptoms

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

Major and mild neurocognitive disorders with behavioral disturbance . The qualifier with behavioral disturbance can be coded into the diagnosis of major or mild neurocognitive disorder. OK, so mood symptoms don’t sound all that behavioral, but that’s how DSM-5 elects to indicate the cognitive disorders with depression.

Adjustment disorder with depressed mood . This term codes one way of adapting to a life stress.

Personality disorders . Dysphoric mood is specifically mentioned in the criteria for borderline personality disorder, but depressed mood commonly accompanies avoidant, dependent, and histrionic personality disorders.

Uncomplicated bereavement . Sadness at the death of a relative or friend is a common experience. Because uncomplicated bereavement is a normal reaction to a particular type of stressor, it is recorded not as a disorder, but as a Z-code [V-code]. See Z63.4 [V62.82] Uncomplicated Bereavement.

Other disorders. Depression can accompany many other mental disorders, including schizophrenia, the eating disorders, somatic symptom disorder, sexual dysfunctions, and gender dysphorias. Mood symptoms are likely in patients with an anxiety disorder (especially panic disorder and the phobic disorders), obsessive–compulsive disorder, and posttraumatic stress disorder.

Specifiers

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

SPECIFIERS DESCRIBING CURRENT OR MOST RECENT EPISODE

These descriptors help characterize the most recent major depressive episode; all but the first two can also apply to a manic episode. (Note that the specifiers for severity and remission are described later.)

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

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

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

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

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

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

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

SPECIFIERS DESCRIBING COURSE OF RECURRING EPISODES

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

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

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

INTRODUCTION TO MOOD EPISODES

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

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

Years ago, the mood disorders were called affective disorders; many clinicians still use the older term, which is also entrenched in the name seasonal affective disorder. Note, by the way, that the term affect covers more than just a patient’s statement of emotion. It also encompasses how the patient appears to be feeling, as shown by physical clues such as facial expression, posture, eye contact, and tearfulness. Emphasis on the actual mood experience of the patient, rather than the sometimes fuzzy concept of affect, dictates the current use of mood.

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

Major Depressive Episode

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

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

Quality of Mood

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

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

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

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

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

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

Duration

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

Symptoms

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

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

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

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

To count as a DSM-5 symptom for major depressive episode, the behaviors listed above must occur nearly every day. However, thoughts about death or suicide need only be “recurrent.” A single suicide attempt or a specific suicide plan will also qualify.

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

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

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

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

1. A symptom is fully explained by another medical condition. For example, you wouldn’t count fatigue in a patient who is recovering from major surgery; in that situation, you expect fatigue.

2. A symptom results from mood-incongruent delusions or hallucinations. For example, don’t count insomnia that is a response to hallucinated voices that keep the patient awake throughout the night.

3. Feelings of guilt or worthlessness that occur because the patient is too depressed to fulfill responsibilities. Such feelings are too common in depression to carry any diagnostic weight. Rather, look for guilt feelings that are way outside the boundaries of what’s reasonable. An extreme example: A woman believes that her wickedness caused the tragedies of 9/11.

Impairment

The episode must be serious enough to cause material distress or to impair the patient’s work (or school) performance, social life (withdrawal or discord), or some other area of functioning, including sex. Of the various consequences of mental illness, the effect on work may the hardest to detect. Perhaps this is because earning a livelihood is so important that most people will go to great lengths to hide symptoms that could threaten their employment.

Exclusions

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

Essential Features of Major Depressive Episode

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

The Fine Print

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

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

Coding Notes

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

The bereavement exclusion that was used through DSM-IV is not to be found in DSM-5, because recent research has determined that depressions closely preceded by the death or loss of a loved one do not differ substantially from depressions preceded by other stressors (or possibly by none at all). There’s been a lot of breast beating over this move, or rather removal. Some claim that it places patients at risk for diagnosis of a mood disorder when context renders symptoms understandable; a substantial expansion in the number of people we regard as mentally ill could result.

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

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

Manic Episode

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

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

The features that must be present in order to diagnose manic episode are identical to those for major depressive episode: (1) A mood quality that (2) has existed for a required period of time, (3) is attended by a required number of symptoms, (4) has resulted in a considerable degree of disability, and (5) violates none of the listed exclusions.

Quality of Mood

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

Duration

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

Symptoms

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

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

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

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

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

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

1. Even during an acute manic episode, many patients have brief periods of depression. These “microdepressions” are relatively common; depending on the symptoms associated with them, they may suggest that the specifier with mixed features is appropriate.

2. Patients may use substances (especially alcohol) in an attempt to relieve the uncomfortable, driven feeling that accompanies a severe manic episode. Less often, the substance use temporarily obscures the symptoms of the mood episode. When clinicians become confused about whether the substance use or the mania came first, the question can usually be sorted out with the help of informants.

3. Catatonic symptoms occasionally occur during a manic episode, sometimes causing the episode to resemble schizophrenia. But a history (obtained from informants) of acute onset and previous episodes with recovery can help clarify the diagnosis. Then the specifier with catatonic features may be indicated.

What about episodes that don’t start until the patient undergoes treatment for a depression? Should they count as fully as evidence of spontaneous mania or hypomania? To count as evidence for either manic or hypomanic episode, DSM-5 requires that the full criteria (not just a couple of symptoms, such as agitation or irritability) be present, and that the symptoms last longer than the expected physiological effects of the treatment. This declaration nicely rounds out the list of possibilities: DSM-IV stated flatly that manic episodes caused by treatment could not count toward a diagnosis of bipolar I disorder, whereas DSM-III-R implied that they could. And DSM-III kept silent on the whole matter.

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

Impairment

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

Exclusions

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

Essential Features of Manic Episode

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