MODIFIERS OF MOOD DIAGNOSES

MODIFIERS OF MOOD DIAGNOSES

MODIFIERS OF MOOD DIAGNOSES

Table 3.3 shows at a glance when and how to apply each of the modifiers of mood disorders covered below.

Severity and Remission

Severity Codes

Neither major depressive episode, manic episode, nor hypomanic episode is codable (stop me if you’ve heard this before). Instead, we use each as the basis for other diagnoses. However, they do have severity codes attached to them, and the same severity codes are used for major depressive and manic episodes. Use these codes for the current or most recent major depressive episode in major depressive, bipolar I, or bipolar II disorders, or the current or most recent manic episode in the two bipolar disorders. (Hypomanic episode is by definition relatively mild, so it gets no severity specifier.)

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The basic severity codes for manic and major depressive episodes are these:

Mild. Symptoms barely fulfill the criteria and result in little distress or interference with the patient’s ability to work, study, or socialize.

Moderate. Intermediate between mild and severe.

Severe. There are several symptoms more than the minimum for diagnosis, and they markedly interfere with patient’s work, social, or personal functioning.

Remission Codes

The majority of patients with bipolar disorders recover completely between episodes (and most of them will have subsequent episodes). Still, up to a third of patients with bipolar I do not recover completely. The figures for patients with major depressive disorder are not quite so grim. Following are two specifiers for current status of both these disorders, as well as bipolar II disorder and persistent depressive disorder (aka dysthymia).

In partial remission. A patient who formerly met full criteria and now either (1) has fewer than the required number of symptoms or (2) has had no symptoms at all, but for under 2 months.

In full remission. For at least 2 months, the patient has had no important symptoms of the mood episode.

Specifiers That Describe the Most Recent Mood Episode

The episode specifiers describe features of the patient’s current or most recent episode of illness. No additional code number is assigned for these features; you just write out the verbiage. Again, Table 3.3 shows at a glance when you can use each of the following special qualifiers.

With Anxious Distress

Patients with bipolar I, bipolar II, cyclothymic, major depressive, or persistent depressive disorder may experience symptoms of high anxiety. These patients may have a greater than average potential for suicide and for chronicity of illness.

Essential Features of With Anxious Distress

During a major depressive/manic/hypomanic episode or dysthymia, the patient feels notably edgy or tense, and may be extra restless. Typically, it is hard to focus attention because of worries—“Something terrible could happen,” or “I could lose control and [fill in the awful consequence] . . . ”

Coding Notes

Specify severity: mild (2 symptoms of anxious distress), moderate (3 symptoms), moderate–severe (4–5 symptoms), severe (4–5 symptoms plus physical agitation)

See Table 3.3 for application.

There’s something kind of funny here. We’ve been given a mood specifier that has its own severity scale, derived (as are manic and major depressive episodes) by counting symptoms. If there’s any other place in DSM-5 where it’s possible to have two separate severity ratings in the same diagnosis, I don’t recall it. (Other specifiers have several symptoms to count; for example, why don’t we also rate severity of with melancholic features?) Furthermore, it is at least theoretically possible for a patient to have mild depression with severe anxious distress. Of course, you can rate each part independently, but it could be confusing and it sounds a little silly. My approach would be to focus on the severity of the mood episode. The specifier will probably get along just fine on its own.

With Atypical Features

Not all seriously depressed patients have the classic vegetative symptoms typical of melancholia (see below). Patients who have atypical features seem almost the reverse: Instead of sleeping and eating too little, they sleep and eat too much. This pattern is especially common among younger (teenage and college-age) patients. Indeed, it is common enough that it might better be called nonclassic depression.

Two reasons make it important to specify with atypical features. First, because such patients’ symptoms often include anxiety and sensitivity to rejection, they risk being mislabeled as having an anxiety disorder or a personality disorder. Second, they may respond differently to treatment than do patients with melancholic features. Atypical patients may respond to specific antidepressants (monoamine oxidase inhibitors), and may also show a favorable response to bright light therapy for seasonal (winter) depression.

Iris McMaster’s bipolar II disorder included atypical features.

Essential Features of With Atypical Features

A patient experiencing a major depressive episode feels better when something good happens (“mood reactivity,” which obtains whether the patient is depressed or well). The patient also has other atypical symptoms: an increase in appetite or weight (the classic depressed patient reports a decrease), excessive sleeping (as opposed to insomnia), a feeling of being sluggish or paralyzed, and long-existing (not just when depressed) sensitivity to rejection.

The Fine Print

The with atypical features specifier cannot be used if your patient also has melancholia or catatonic features. See Table 3.3 for application.

With Catatonia

The catatonia specifier, first mentioned in Chapter 2 in association with the psychotic disorders, can be applied to manic and major depressive (but not hypomanic) episodes of mood disorders as well. The definitions of the various terms are given in the sidebar. When you use it, you have to add a line of extra code after listing and coding the other mental disorder:

I’ve given an example in the case of Edward Clapham.

With Melancholic Features

The with melancholic features specifier refers to the classical “vegetative” symptoms of severe depression and a negative view of the world. Melancholic patients awaken too early in the morning, feeling worse than they do later in the day. They also have reduced appetite and lose weight. They take little pleasure in their usual activities (including sex) and are not cheered by the presence of people whose company they normally enjoy. This loss of pleasure is not merely relative, but total or nearly so. Brian Murphy is an example of such a patient; Noah Sanders is another.

Melancholic features are especially common among patients who first develop severe depression in midlife. This condition used to be called involutional melancholia, from the observation that it seemed to occur in patients who were in middle to old age (life’s so-called “involutional” period). However, it is now recognized that melancholic features can affect patients of any age; they are especially likely to occur in psychotic depressions. Depression with melancholia usually responds well to somatic treatments such as antidepressant medication and ECT. Contrast this picture with that given for with atypical features (see above).

Again, see Table 3.3 for details of when to apply this specifier.

Essential Features of With Melancholic Features

In the depths of a major depressive episode, the patient cannot find pleasure in accustomed activities or feels no better if something good happens (OK, could be both). Such a patient also experiences some of these: a mood more deeply depressed than what you’d expect during bereavement; diurnal variation of mood (more depressed in the morning); terminal insomnia (awakening at least 2 hours early); change in psychomotor activity (sometimes agitated, more often slowed down); marked loss of appetite or weight; and guilt feelings that are unwarranted or excessive. This form of depression is extremely severe and can border on psychosis.

Coding Notes

You can apply this specifier to a major depressive episode, wherever it occurs: major depressive disorder (single episode or recurrent), bipolar I or II disorder, or persistent depressive disorder. See Table 3.3.

With Mixed Features

In 1921, Emil Kraepelin first described mixed forms of mania and depression. DSM-IV and its predecessors included a mixed episode among the mood disorders. Now that it’s been retired, DSM-5 offers a with mixed features specifier to use with patients who within the same time frame have symptoms of depression and mania (or hypomania). The features of the two opposite poles occur more or less at the same time, though some patients experience the gradual introduction (then fading away) of, say, depression into a manic episode.

However, researchers are only just ascertaining the degree to which such a patient differs from someone with “pure” episodic mania or depression. Patients who have mixed features appear to have more total episodes and more depressive episodes, and remain ill longer. They may tend to have more comorbid mental illness and greater suicide risk. Their work is more likely to be impaired. Patients with major depressive disorder who have mixed features are especially likely to develop a bipolar disorder in the future.

Despite this attention, we’ll probably continue to use the with mixed features specifier less often than could be justified. Several studies suggest that a third or more of bipolar patients have at least one episode with mixed symptoms; some reports suggest that mixed mood states are more frequent in women than in men.

You can apply this specifier to episodes of major depression, mania, and hypomania (see Table 3.3). Because of the greater impairment and overall severity of mania symptoms, if you have a patient who meets full criteria for both mania and major depression, you should probably go with the diagnosis of bipolar I disorder with mixed features, rather than major depressive disorder with mixed features. Winona Fisk had bipolar I disorder with mixed features.

The criteria for with mixed features omit some of the mood symptoms found in manic and major depressive episodes. That’s because they might conceivably belongon both lists, and hence do not indicate a mixed presentation. These symptoms include certain problems with sleep, appetite/weight, irritability, agitation, and concentration. Note, by the way, that the patient must meet full criteria for major depressive, manic, or hypomanic episode.

The criteria are silent as to how long each day (or, actually, the majority of days) the mixed features must be present, and I don’t know of any data that would help us understand this question better. Right now, even a few minutes a day, repeated day after day, would seem enough to earn this specifier. Only additional research is going to help us understand whether that’s a sensible time frame—or too short, or too long. Right now, that picture is decidedly mixed.

Essential Features of With Mixed Features

Here, there are two ways to go.

A patient with a manic or hypomanic episode also has some noticeable symptoms of depression most days: depressed mood, low interest or pleasure in activities, an activity level that is speeded up or slowed down, feeling tired, feeling worthless or guilty, and repeated thoughts about death or suicide. (See Coding Note.)

A patient with major depressive episode also has some noticeable symptoms of mania most days: heightened mood, grandiosity, increased talkativeness, flight of ideas, increased energy level, poor judgment (such as excessive spending, sexual adventures, imprudent financial speculations), and reduced need for sleep.

The Fine Print

The D: • Differential diagnosis (physical disorders, substance use disorders)

Coding Note

The impairment and severity of full-blown mania suggest that patients who simultaneously meet full episode criteria for both manic and depressive episodes should be recorded as having manic episode, with mixed features.

With Peripartum Onset

Over half of all women have “baby blues” after giving birth: They may feel sad and anxious, cry, complain of poor attention, and have trouble sleeping. This lasts a week or two and is usually of little consequence. But about 10% of women have enough symptoms to be diagnosed as having a depressive disorder; these people often have a personal history of mental disorder. An episode of hypomania may be especially likely after childbirth. Only about 2 out of 1,000 new mothers actually become psychotic.

The with peripartum onset specifier has the briefest Essential Features in this book. Though Elisabeth Jacks had a manic episode after giving birth, a major depressive episode would be much the more common response. With peripartum onset can apply to bipolar I and bipolar II disorders, to either type of major depressive disorder, or to brief psychotic disorder (see Table 3.3 for all applications except to brief psychotic disorder).

Essential Features of With Peripartum Onset

A female patient’s mood disorder starts during pregnancy or within a month of giving birth.

Coding Notes

See Table 3.3 for application.

In the mood disorders, it’s called with peripartum onset. However, when it occurs with brief psychotic disorder, it’s called with postpartum onset, even though it’s described there as occurring “during pregnancy or within 4 weeks postpartum.” This is just one more little glitch that will probably get sorted out, by and by. Use it either way in any context, and you’re still likely to be understood.

With Psychotic Features

Irrespective of the severity rating, some patients with manic or major depressive episodes will have delusions or hallucinations. (Of course, most of these patients you will have rated as being severely ill, but it is at least theoretically possible that someone could have just a few symptoms—including psychosis—that for whatever reason haven’t hugely inconvenienced them.) Around half of patients with bipolar I disorder will have psychotic symptoms; far fewer patients with major depressive disorder will be psychotic.

Psychotic symptoms may be mood-congruent or mood-incongruent. Specify, if possible:

With mood-congruent psychotic features. The content of the patient’s delusions or hallucinations is completely in accord with the usual themes of the relevant mood episode. For major depression, these include death, disease, guilt, delusions of nihilism (nothingness), personal inadequacy, or punishment that is deserved; for mania, they include exaggerated ideas of identity, knowledge, power, self-worth, or relationship to God or someone else famous.

With mood-incongruent psychotic features. The content of the patient’s delusions or hallucinations is not in accord with the usual themes of the mood episode. For both mania and major depression, these include delusions of persecution, control, thought broadcasting, and thought insertion.

Essential Features of With Psychotic Features

The patient has hallucinations or delusions.

Coding Notes

Specify, if possible:

With mood-congruent psychotic features. The psychotic symptoms match what you’d expect from the basic manic or depressive mood (see above).

With mood-incongruent psychotic features. They don’t match.

Specifiers That Describe Episode Patterns

Two specifiers describe the frequency or timing of mood episodes. Their appropriate uses are summarized below in Table 3.3, as are those for the other types of specifiers.

With Rapid Cycling

Typically, the bipolar disorders follow a more or less indolent course: a number of months (perhaps 3–9) of depression, followed by somewhat fewer months of mania or hypomania. Other than their number, the individual episodes meet full criteria for major depressive, manic, or hypomanic episodes. As patients age, the entire cycle tends to speed up, but most patients have no more than one up-and-down cycle per year, even after five or more complete cycles. Some patients, however, especially women, cycle much more rapidly than this: They may go from mania to depression to mania again within a few weeks. (Their symptoms meet full mood episode requirements—that’s how they differ from cyclothymic disorder.)

Recent research suggests that patients who cycle rapidly are more likely to originate from higher socioeconomic classes; in addition, a past history of rapid cycling predicts that this pattern will continue in the future. Rapid cyclers may be more difficult to manage with standard maintenance regimens than other patients, and they may have a poorer overall prognosis. With rapid cycling can apply to bipolar I and bipolar II disorders.

Essential Features of With Rapid Cycling

A patient has four or more episodes per year of major depression, mania, or hypomania.

Coding Notes

To count as a separate episode, an episode must be marked by remission (part or full) for 2+ months or by a change in polarity (such as from manic to major depressive episode).

With Seasonal Pattern

Here is yet another specifier for mood disorders that has only been recognized in the last few decades. In the usual pattern, depressive symptoms (these are often also atypical) appear during fall or winter months and remit in the spring and summer. Patients with winter depression may report other difficulties, such as pain disorder symptoms or a craving for carbohydrates, during their depressed phase. Winter depressions occur more commonly in polar climates, especially in the far North, and younger people may be more susceptible. With seasonal pattern can apply to bipolar I and bipolar II disorders and to major depressive disorder, recurrent type. There may also be seasonality to manic symptoms, although this is far less well established. (Bipolar I patients may experience the seasonal pattern with one type of episode, not with the other.)

Sal Camozzi’s bipolar II disorder included a seasonal pattern. His history is presented in Chapter 11.

Essential Features of With Seasonal Pattern

The patient’s mood episodes repeatedly begin (and end) at about the same times of year. The seasonal episodes have been the only episodes for at least the past 2 years. Lifelong, seasonal episodes materially outnumber nonseasonal ones

The Fine Print

Disregard examples where there is a clear seasonal cause, such as being laid off every summer.

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