Mood Disorders

1. Mood Disorders

2. Core Concept • People with this diagnosis have an abnormal mood characterized by: • Depression • Mania, or • Both symptoms in alternating fashion • The abnormal mood may or may not impair the person’s social or occupational functioning.

3. Definitions • Depression • Unusually sad, gloomy, and dejected mood, or • Markedly diminished interest and pleasure in everyday activities that is distinctly different from the person’s non-depressed state. • Mania • Unusually and persistently elevated, expansive, or irritable mood that is distinctly different from the person’s non-manic state • Marked impairment, requires hospitalization • Hypomania • Less severe variant of mania; no hospitalization

4. Quick Guide: Four Criteria Sets I. Mood Episodes, pgs. 349, 357, 362, and 365. II. Mood Disorders, pgs. 369 - 410 III. Specifiers, describing most recent mood episode, pgs. 410- 422. IV. Specifiers, describing course of recurrent episodes. pgs. 423-428.

5. I. Mood Episodes (Quick Guide) • Similar to the two criteria sets we used to determine if a client met the criteria for Panic Attack or Agoraphobia. • Remember that these were not codable • Also they were not diagnoses; i.e., they were not anxiety disorders • Mood Episodes are: • Not codable – not diagnoses. • The “building blocks” from which many of the codable mood disorders are constructed. • Most mood disorder clients will have one or more of the four types of mood episode:

6. The four types of Mood Episodes are: • Major Depressive Episode, p. 349, 356 • Manic Episode, p. 357, 362 • Mixed Episode, p, 362, 365 • Hypomanic Episode, p. 365, 368

7. Major Depressive Episode p. 349, 356 For at least two weeks the client feels: • Depressed ( or cannot enjoy life) • and has: • Problems with eating and sleeping • Guilt feelings • Loss of energy • Trouble concentrating, and • Thoughts about death

8. Manic Episode p. 357, 362 For at least one week, the client feels: • Elated (or sometimes only irritable) and • May be grandiose, talkative, hyperactive, and distractible • Bad judgment leads to marked social or work impairment • Often client must be hospitalized

9. Mixed Episode p. 362, 365 The client has fulfilled the symptomatic criteria for both a Manic and a Major Depressive Episode. But episode has lasted as briefly as one week.

10. Hypomanic Episode p. 365, 368 A Hypomanic Episode is much like a Manic Episode; however, it is: • Briefer and • Less severe Hospitalization is not required.

11. Four Criteria Sets I. Mood Episodes, p. 349, 357, 362, and 365. II. Mood Disorders, p. 369 - 410 III. Specifiers, describing most recent mood episode, p. 410- 422. IV. Specifiers, describing course of recurrent episodes, p. 423-428.

12. II. Mood Disorders • A mood disorder is a pattern of illness due to an abnormal mood. • Nearly every client with a mood disorder experience depression at some time • But some clients also have highs of mood • Many, but not all, mood disorders are diagnosed on the basis of a mood episode

13. Most clients with Mood Disorders fit into one of the following codable categories • Depressive Disorders • Bipolar Disorders • Other Mood Disorders • Other Causes of Depressive and Manic Symptoms

14. Depressive Disorders a. Major Depressive Disorder: 296.2x Major Depressive Disorder, Single Episode 296.3x Major Depressive Disorder, Recurrent Type • Client has no Manic or Hypomanic Episodes, • But has had one or more Major Depressive Episodes b. 300.4 Dysthymic Disorder • Not severe enough to be call a Major Depressive Episode • Lasts much longer than Major Depressive Disorder • No high phases c. 311 Depressive Disorder Not Otherwise Specified (NOS) • Client has depressive symptoms that do not meet criteria for the a. or b. (above) or any other diagnosis in which depression is a feature.

15. Bipolar Disorders • Approximately 25% of mood disorder clients experience Manic or Hypomanic Episodes. • Nearly all of these clients also have episodes of depression. • The severity and duration of the highs and lows determine the specific mood disorder

16. 2. Bipolar Disorders (con’t.) a. Bipolar I Disorder • Must have at least one Manic Episode • Most Bipolar I clients also have had a Major Depressive Episode b. Bipolar II Disorder • At least one Hypomanic Episode, plus • At least one Major Depressive Episode c. Cyclothymic Disorder • Repeated mood swings, but • None severe enough to be called Major Depressive Episodes or Manic Episode d. Bipolar Disorder NOS • Client has bipolar symptoms that do not meet the criteria for the bipolar diagnoses above

17. Bipolar Disorders (con’t.) a. 296.xx Bipolar I Disorder (1) 296.0x Bipolar I Disorder, Single Manic Episode (2) 296.40 Bipolar I Disorder, Most Recent Episode Hypomanic (3) 206.4x Bipolar I Disorder, Most Recent Episode Manic (4) 296.6x Bipolar I Disorder, Most Recent Episode Mixed (5) 296.5x Bipolar I Disorder, Most Recent Episode Depressed (6) 296.7 Bipolar I Disorder, Most Recent Episode Unspecified b. 296.89 Bipolar II Disorder c. 301.13 Cyclothymic Disorder d. 296.80 Bipolar Disorder NOS

18. 3. Other Mood Disorders • Mood Disorder Due to a General Medical Condition. • Substance-Induced Mood Disorder • Mood disorder NOS For clients who don’t fit into any of the mood disorder categories mentioned.

19. Four Criteria Sets I. Mood Episodes, pgs. 349, 357, 362, and 365. II. Mood Disorders, pgs. 369 - 410 III. Specifiers, describing most recent mood episode, pgs. 410- 422. IV. Specifiers, describing course of recurrent episodes. pgs. 423-428.

20. Specifiers Two sets of descriptions can be applied to a number of the mood episodes and mood disorders. • III. Specifiers Describing Most Recent Episode • IV. Specifiers Describing Course of Recurrent Episodes

21. III. Specifiers for Most Recent Episode • With Atypical Features Clients eat a lot, gain weight, sleep excessively, feel leaden, & sensitive to rejection. (D, only) • With Melancholic Features Clients awake early and feel worse early in day, lose appetite and weight, feel guilty, slowed down or agitated. (D, only) • With Catatonic Features Motor hyperactivity or inactivity (D or/& M episode) • With Postpartum Onset Within month of having a baby (D & M episode)

22. IV. Specifiers for Course of Recurrent Episodes • With or Without Full Interepisode Recovery. That is the presence (of absence) of symptoms between Manic, Hypomanic, Mixed, or Major Depressive Episodes • With Rapid Cycling. Within one year, the client has had at least four episodes (in any combination) meeting criteria for Major Depression, Mania, Mixed, and/or Hypomanic episodes • With Seasonal Pattern. Client becomes ill at certain times of the year, e.g., fall or winter.

23. 4. Other Causes of Depressive and Manic Symptoms • Schizoaffective Disorder Schizophrenia can co-exist with a Major Depressive or a Manic Episode. • Cognitive disorders with depressed mood. The qualifier “With Depressed Mood” can be coded into the diagnosis of Dementia of the Alzheimer’s Type or Vascular Dementia. A delirium can often begin with depression anxiety, or other expressions of dysphoria.

24. 4. Other Causes of Depressive and Manic Symptoms (con’t.) • Adjustment Disorder With Depressed Mood. • Personality disorders. A mood disorder can accompany Borderline, Avoidant, Dependent and Histrionic Personality Disorders • Bereavement. Common event, but when symptoms last longer than two months, a mood disorder might be present • Other Disorders:

25. 4. Other Causes of Depressive and Manic Symptoms (cont.) Depression can also accompany: • Schizophrenia • Eating Disorders • Somatization Disorder, and • Sexual and Gender Identity disorders. Mood symptoms can also be present in: • Anxiety Disorders, especially Panic Disorder, Obsessive-Compulsive Disorder, Phobic Disorder, and PTSD.

26. Depression and Children • Children can have depression - more likely than adults to manifest itself as somatic complaints, irritability, phobias, school problems, acting out, social withdrawal. • Children/Teens with a combination of depressed mood and self-deprecatory ideation are particularly likely to have a mood disorder. • Bipolar disorders are rare in children.

27. Depression and Elderly • Depression occurs for the first time in10% to 20% of population over the age of 60 years. • Mood disorder is different in later life: • Melancholia seems more prevalent among the elderly than other ages. • Mood disorders seem to worsen with age. • Psychomotor agitation, delusions, loss of appetite, memory loss, distractibility, and disorientation are common symptoms. • Depression is often missed in the elderly, because behavior is often attributed erroneously to somatic concerns, cognitive deficits, medication side effects, or expectable changes of old age. • One way to tell if depression is causing the symptoms: Depression has a more rapid onset than above disorders.

28. Depression and Children • Children can have depression - more likely than adults to manifest itself as somatic complaints, irritability, phobias, school problems, acting out, social withdrawal. • Children/Teens with a combination of depressed mood and self-deprecatory ideation are particularly likely to have a mood disorder. • Bipolar disorders are rare in children.

29. Depression and Elderly • Depression occurs for the first time in10% to 20% of population over the age of 60 years. • Mood disorder is different in later life: • Melancholia seems more prevalent among the elderly than other ages. • Mood disorders seem to worsen with age. • Psychomotor agitation, delusions, loss of appetite, memory loss, distractibility, and disorientation are common symptoms. • Depression is often missed in the elderly, because behavior is often attributed erroneously to somatic concerns, cognitive deficits, medication side effects, or expectable changes of old age. • One way to tell if depression is causing the symptoms: Depression has a more rapid onset than above disorders.

30. Gender Differences • Depression is far more common among women than men. • Women are also more prone than men to experience recurrent depressive episodes. • Both biological and social factors play a part in these patterns. For example, women who experience severe premenstrual mood changes are more vulnerable to other mood disorders including postpartum depression. • For bipolar disorder, men and woman are equally represented. About 25% of people who are depressed are also bipolar.

31. Culture Differences • Depression may differ from culture to culture with regard to age of onset, symptoms, course, etc. • For example, in many non-Western cultures, depression is more likely to be experienced in somatic (through not feeling well in the body), rather than affective terms (feelings emotionally low).

32. One Possible Cause of Depression • Seems to have genetic basis. • Does run in families. See statistics in DSM-IV-TR. • Article in Science magazine, May 1997 Found one portion of the brain is significantly smaller and less active in people suffering from hereditary depression. A tiny, thimble-size nodule of the brain, located about 2-1/2 inches behind the bridge of the nose, called the subgenera prefrontal cortex, plays a part in controlling emotions. The study found that in depressed people, this part, according to PET scans, was less active in depressed individuals than in non-depressed people. So researchers scanned using MRI. They found that, on the average, 39% to 48% less brain tissue in the affected region of the brain of depressed patients.

33. Treatment • It appears that therapy alone is as good, if not better, than medication alone. • Using both medication and therapy, outcome may even be better.