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Mood Disorders

Mood Disorders. Part II. Episodes. Major Depressive Episode Manic Episode Hypomanic Episode Mixed Episode These are the building blocks for the mood D/Os. They themselves are not coded, but are the components of the coded D/Os. Major Depressive Disorder (296.xx).

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Mood Disorders

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  1. Mood Disorders Part II

  2. Episodes • Major Depressive Episode • Manic Episode • Hypomanic Episode • Mixed Episode • These are the building blocks for the mood D/Os. They themselves are not coded, but are the components of the coded D/Os.

  3. Major Depressive Disorder (296.xx) • One or more Major Depressive Episodes (i.e. 2 weeks or more of depressed mood + 4 additional symptoms of depression) • No history of Manic, Hypomanic or Mixed Episodes

  4. Major Depressive Disorder (296.xx) • Associated features • High mortality rate • About 15% of those with this disorder commit suicide • Culture, Age & Gender • There may be different types of symptoms in different cultures • There may also be different attitudes in expressing depressive feelings in different cultures • Increased somatic complaints in children • Increased cognitive symptoms in adults • Occurs twice as frequently in women as men

  5. Major Depressive Disorder (296.xx) • Course • Can begin at any age • Mean onset in mid-20s • Variable course in most individuals • Episodes end completely in about 2/3 of those diagnosed with this D/O • However, the incidence of one episode increases the chance of another episode, with the probability increasing for each subsequent episode (e.g. it gets progressively worse if not treated).

  6. Major Depressive Disorder (296.xx) • Differential diagnosis • Rule out medical condition and substance/medication use • Differentiate from Dysthymic Disorder by severity, chronicity and persistence • Can be given with Maj. Dep. D/O if the symptoms occurred for 2 years without a Depressive Episode, or if the Maj. Dep. D/O is in remission for 2 months before the onset of the Dysthymia

  7. Major Depressive Disorder (296.xx) • Differential diagnosis • Schizoaffective Disorder • There must be a two week period of psychotic symptoms outside of a mood episode • Psychotic D/O • There may be some symptoms of depression in those with these D/O. However, if the criteria are met for a Depressive Episode, the addition diagnosis of Depressive D/O NOS is added.

  8. Major Depressive D/OCourse specifiers • 4th Digit • 296.2x • Single episode • 296.3x • Recurrent episodes

  9. Major Depressive D/OSeverity Specifier • 5th digit • Clinical status of current (or most recent) mood • 296.21 Single episode, mild • 296.22 Single episode, moderate • 296.23Single episode, severe without psychotic symptoms • 296.24 Single episode, severe with psychotic symptoms • 296.25Single episode, in partial remission • 296.26 Single episode, in full remission • 296.20 Single episode, unspecified

  10. Major Depressive & Bipolar D/OFeatures Specifier • Catatonic • Waxy flexibility or stupor • Excessive motor activity that does not appear to be externally influenced • Rigid posture • Mutism • Other peculiarities of voluntary movement • Echolalia • Echopraxia

  11. Major Depressive & Bipolar D/OFeatures Specifier • Melancholic • Loss of pleasure in all or almost all activities • Mood does not improve, even when something good happens • Distinctive depressed mood (different from bereavement or feeling sad) • Depression worse in the morning • Early morning awakening • Psychomotor retardation or agitation • Significant anorexia or weight loss • Excessive or inappropriate guilt

  12. Major Depressive & Bipolar D/OFeatures Specifier • Atypical • Mood reactivity • Significant weight gain or increase in appetite • Hypersomnia • Leaden paralysis • Long standing pattern of interpersonal rejection sensitivity (pathological sensitivity to being rejected by others) resulting in impaired social or occupational functioning

  13. Major Depressive & Bipolar D/OAdditional Course Specifiers • Rapid Cycling • 4 episodes of a Mood Episode in the past 12 months • There is a 2 month partial or full remission between episodes, or episodes switch to the opposite polarity • Longitudinal • With full interepisode recovery • Without full interepisode recovery

  14. Major Depressive & Bipolar D/OAdditional Course Specifiers • Postpartum onset • Depressive episode which occurs within 4 weeks of giving birth • Seasonal pattern • There is a regular temporal relationship between the onset of the Mood D/O and a particular time of year • Full remission occur in between seasonal episodes (or a shift from depression to mania) • Seasonal episode outnumber non-seasonal episodes

  15. Dysthymic Disorder (300.4) • 2 years of depressed mood more days than not • During periods of depressed mood, at least 2 of the following are present: • Poor appetite or over eating • Insomnia or hypersomnia • Low energy/fatigue • Low self esteem • Poor concentration or difficulty making decisions • Feelings of hopelessness • Symptom free intervals last no more than 2 months • No Manic, Hypomanic or Mixed Episodes

  16. Dysthymic Disorder (300.4) • Specifiers • Early Onset • Before age 21 years • Increased risk of developing Maj. Dep. D/O • Late Onset • Age 21 or older • With Atypical Features • Same criteria as with Maj. Dep. D/O

  17. Dysthymic Disorder (300.4) • Associated features • Feelings of inadequacy • Generalized loss of interest • Social withdrawal • Feelings of guilt or brooding about the past • Subjective irritability or anger • Decreased activity or productiveness

  18. Dysthymic Disorder (300.4) • Culture, Age & Gender • Occurs equally in both genders • Children & adolescents will present with symptoms of irritability and crankiness • Course • Early, insidious onset and chronic course • May also develop Maj. Dep. D/O • Those with Maj. Dep. D/O may not have full inter-episode recovery from depressed symptoms

  19. Dysthymic Disorder (300.4) • Differential Diagnosis • Rule out medical condition and substance/medication use • Take a careful history of the client’s experiences of depression, as this disorder is hard to tease apart from Major Depressive Disorder • May also occur with a Personality Disorder. If so, both are given.

  20. Depressive Disorder NOS (311) • Exhibits depressive features, but does not meet criteria for • Maj. Dep. D/O • Dysthymic D/O • Adj. D/O with Depressed Mood • Adj. D/O with Mixed Anxiety & Depressed Mood • Or exhibits depressed symptoms about which there is inadequate or contradictory information

  21. Bipolar I Disorder (296.xx) • One or more Manic or Mixed episodes, usually accompanied by Major Depressive Episodes • Recurrent episodes are indicated by a shift in polarity or interval between episodes of at least 2 months.

  22. Bipolar I Disorder (296.xx) • Associated features • High morbidity • Suicide rates is 10% - 15% • More likely to occur during Depressive or Mixed state • High occurrence of spouse abuse and child abuse • Other features • School truancy • School failure • Occupational failure • Divorce • Episodic antisocial behavior

  23. Bipolar I Disorder (296.xx) • Culture, Age & Gender • No differential in race, age, gender or ethnicity • Overdiagnosis of Schizophrenia (instead of Bipolar) among some ethnic groups

  24. Bipolar I Disorder (296.xx) • Males • First episode tends to be Manic • Number of Manic Episodes exceeds number of Depressive Episodes • Females • First episode tends to be Major Depressive • Number of Depressive Episodes tends to outnumber Manic • Rapid Cycling is more common in women • Women with Bipolar I are at increased risk for additional episodes post-partum

  25. Bipolar I Disorder (296.xx) • Course • Age of onset is about 20 years old • Recurrent & chronic • 90% of those with a Manic Episode will have another • 60% - 70% of Manic Episodes immediately follow a Depressive Episode • Interval between episodes tends to decrease with age • 20% - 30% display mood lability between episodes

  26. Bipolar I Disorder (296.xx) • Familial Pattern • Strong genetic influence • Some studies indicate an increased risk of 25% in those having one parent with Bipolar D/O, and a 50% - 75% increased risk in those having both parents with Bipolar D/O

  27. Bipolar I Disorder (296.xx) • Differential Diagnosis • Rule out medical condition and substance/medication use, yadda, yadda, yadda… • Look at severity and intensity to differentiate from a Hypomanic Episode and Cyclothymic Disorder

  28. Bipolar I Disorder (296.xx) • Schizoaffective Disorder • There must be a two week period of psychotic symptoms outside of a mood episode • Psychotic D/O • There may be some symptoms of mania in those with these D/O. However, if the criteria are met for a Manic or Mixed Episode, the addition diagnosis of Bipolar D/O NOS is added.

  29. Bipolar I D/OMost recent episode Specifier • 4th digit • 296.0x Single Manic Episode • 296.4x Current or most recent episode is Hypomanic or Manic Episode • 296.5x Current or most recent episode is a Depressive Episode • 296.6x Current or most recent episode is a Mixed Episode • 296.7Current or most recent episode is unspecified (Notice there is no fifth digit for this option. It’s the only Mood D/O without one).

  30. Bipolar I D/OMost recent episode Specifier • 5th digit • 296.40(This one is a bit different). • Bipolar I Disorder, most recent episode Hypomanic AND • Bipolar I Disorder, most recent episode Manic, unspecified

  31. Bipolar I D/OSeverity Specifier • 5th digit • Clinical status of current (or most recent) mood • 296.41 Bipolar I Disorder, most recent episode Manic, Mild • 296.42Bipolar I Disorder, most recent episode Manic, Moderate • 296.43Bipolar I Disorder, most recent episode Manic, Severe,without psychotic features • 296.44 Bipolar I Disorder, most recent episode Manic, Severe,with psychotic features • 296.45Bipolar I Disorder, most recent episode Manic, in partial remission • 296.46Bipolar I Disorder, most recent episode Manic, in full remission

  32. Major Depressive & Bipolar D/OFeatures Specifier • Catatonic • Waxy flexibility or stupor • Excessive motor activity that does not appear to be externally influenced • Rigid posture • Mutism • Other peculiarities of voluntary movement • Echolalia • Echopraxia

  33. Major Depressive & Bipolar D/OFeatures Specifier • Melancholic • Loss of pleasure in all or almost all activities • Mood does not improve, even when something good happens • Distinctive depressed mood (different from bereavement or feeling sad) • Depression worse in the morning • Early morning awakening • Psychomotor retardation or agitation • Significant anorexia or weight loss • Excessive or inappropriate guilt

  34. Major Depressive & Bipolar D/OFeatures Specifier • Atypical • Mood reactivity • Significant weight gain or increase in appetite • Hypersomnia • Leaden paralysis • Long standing pattern of interpersonal rejection sensitivity (pathological sensitivity to being rejected by others) resulting in impaired social or occupational functioning

  35. Major Depressive & Bipolar D/OAdditional Course Specifiers • Rapid Cycling • 4 episodes of a Mood Episode in the past 12 months • There is a 2 month partial or full remission between episodes, or episodes switch to the opposite polarity • Longitudinal • With full interepisode recovery • Without full interepisode recovery

  36. Major Depressive & Bipolar D/OAdditional Course Specifiers • Postpartum onset • Depressive episode which occurs within 4 weeks of giving birth • Seasonal pattern • There is a regular temporal relationship between the onset of the Mood D/O and a particular time of year • Full remission occur in between seasonal episodes (or a shift from depression to mania) • Seasonal episode outnumber non-seasonal episodes

  37. Bipolar II Disorder (296.89) • One or more Major Depressive Episodes, accompanied by at least one Hypomanic Episode • Specifiers • Hypomanic • Used if the current or most recent episode is Hypomanic • Depressed • Used if the current or most recent episode is Depressive

  38. Bipolar II Disorder (296.89) • Specifiers • If the criteria for a Maj. Dep. D/O are met, the following additional specifiers may be used • Mild, moderate, severe without psychotic features, severe with psychotic features • Catatonic, Melancholic, Atypical, Postpartum onset • If the full criteria are not currently met for a Hypomanic or Maj. Dep. Episode, the following specifiers may be used to describe the current clinical state, or the most recent Maj. Dep Episode • Partial remission, full remission • Catatonic, Melancholic, Atypical, Postpartum onset

  39. Bipolar II Disorder (296.89) • Associated features • High morbidity • Suicide rates is 10% - 15% • Increased risk for truancy, school failure occupational failure and divorce

  40. Bipolar II Disorder (296.89) • Gender features • More common in women than in men • Males • More Hypomanic than Depressive Episodes • Females • More Depressive Episodes • Increased frequency of Rapid Cycling • Increased risk of developing D/O post-partum

  41. Bipolar II Disorder (296.89) • Course • 60%-70% of the Hypomanic Episodes occur immediately after a Maj. Dep. Episode • Interval between episodes tends to decrease with age • About 15% of those with this D/O continue to experience some symptoms in between episodes

  42. Bipolar II Disorder (296.89) • Differential Diagnosis • Rule out medical condition and substance/medication use, yadda, yadda, yadda… • When a person with Maj. Dep. D/O experiences at least one Hypomanic Episode, the diagnosis is changed to Bipolar II • Bipolar II is distinguished from Cyclothymia by the presence of one or more Maj. Dep D/O • Schizoaffective Disorder & Psychotic D/O • Psychotic symptoms must be present outside of a mood episode

  43. Cyclothymic Disorder (301.13) • 2 years of numerous hypomanic symptoms that do not meet the criteria for a Manic Episode, and numerous periods of depressive symptoms that do not meet the criteria for a Major Depressive Episode • During the 2 years, there can be no Maj. Dep., Manic, or Hypomanic Episodes

  44. Cyclothymic Disorder (301.13) • Age & Gender features • Begins early in life • Occurs equally in men and women • Course • Begins in adolescence or early adulthood • Insidious onset and chronic course

  45. Cyclothymic Disorder (301.13) • Differential Diagnosis • One more time, rule out medical condition and substance/medication use. • Specifically, a late onset of Cyclothymia may suggest a Mood D/O due to a general medical condition • Distinguished from Bipolar I or II with rapid cycling when the mood states do not meet the full criteria for a Maj. Dep, Manic or Mixed Episode • Make sure you consider Borderline Personality Disorder, which usually presents with labile and variable mood

  46. Bipolar Disorder, NOS (296.80) • Exhibits bipolar features, but does not meet criteria for any specific Bipolar Disorder • Exhibits bipolar symptoms about which there is inadequate or contradictory information

  47. Mood Disorder due to a …(list the General Medical Condition) (293.83) • Exhibits prominent and persistent mood disturbance that is a direct physiological consequence of a General Medical Condition (Code condition on Axis III) • Specifiers include • With Depressive Features • With Major Depressive-like Episode • With Manic Features • With Mixed Features

  48. Substance Induced Mood Disorder 29x.xx (Coding is dependent on the type of drug used) • Exhibits prominent and persistent mood disturbance that is a direct physiological consequence of a drug of abuse, a medication another somatic treatment for depression or toxin exposure • Specifiers include • With Depressive Features • With Manic Features • With Mixed Features • With onset during intoxication • With onset during withdrawal

  49. Mood Disorder NOS (296.90) • Use for coding disorders with mood symptoms that do not meet criteria for any other Mood D/O, and for which it is hard to choose between Depressive Disorder NOS and Bipolar Disorder, NOS.

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