Mood Disorders Due to Another Medical Condition

Mood Disorders Due to Another Medical Condition

Mood Disorders Due to Another Medical Condition

Many medical conditions can cause depressive or bipolar symptoms, and it is vital always to consider physical etiologies when evaluating a mood disorder. This is not only because they are treatable; with today’s therapeutic options, most mood disorders are highly treatable. It is because some of the general medical conditions, if left inadequately treated too long, themselves have serious consequences—including death. And there are not a few that can cause manic symptoms. I’ve mentioned some of these in the “Physical Disorders That Affect Mental Diagnosis” table in the Appendix, though that table is by no means comprehensive.

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Note this really important requirement: The medical condition has to have been the direct, physiological cause of the bipolar or depressive symptoms. Psychological causation (for instance, the patient feels understandably terrible upon being told “it’s cancer”) doesn’t count, except as the possible precipitant for an adjustment disorder.

The vignette of Lisa Voorhees below illustrates the importance of keeping in mind that medical conditions can cause mood disorders.

Essential Features of Depressive Disorder Due to Another Medical Condition

A physical medical condition appears to have caused a patient to experience a markedly depressed mood or loss of interest or pleasure in most activities.

The Fine Print

For pointers on deciding when a physical condition may have caused a mental disorder, see sidebar.

The D’s: • Duration (none stated, though it would not be fleeting) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use disorders, other depressive disorders, delirium)

Coding Notes

Specify:

F06.31 [293.83] With depressive features. You cannot identify full symptomatic criteria for a major depressive episode.

F06.32 [293.83] With major depressive-like episode. You can.

F06.34 [293.83] With mixed features. Manic or hypomanic symptoms are evident but not predominant over the depressive symptoms.

It is only with DSM-5 that criteria have been written specifically differentiating medically induced bipolar from medically induced depressive disorders. What if you can’t tell? Some mood disorders, in their early stages, may be too indistinct to call. You might then be reduced to diagnosing mood disorder due to a medical condition (F06.30) or substance-induced mood disorder (F19.94).

Essential Features of Bipolar and Related Disorder Due to Another Medical Condition

A physical medical condition appears to have caused a patient to experience both an elevated (or irritable) mood and an atypical increase in energy or activity, though full manic episode symptoms may not be present.

The Fine Print

For pointers on deciding when a physical condition may have caused a mental disorder, see sidebar.

The D’s: • Duration (none stated, though it would not be fleeting) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use disorders, other bipolar disorders, other mental disorders, delirium)

Coding Notes

Specify:

F06.33 [293.83] With manic- or hypomanic-like episode. You can identify full symptomatic criteria for mania or hypomania.

F06.33 [293.83] With manic features. Full mania or hypomania criteria are not met.

F06.34 [293.83] With mixed features. Depressive symptoms are evident but not predominant over the manic symptoms.

Lisa Voorhees

By the time she arrived at the mental health clinic, Lisa Voorhees had already seen three doctors. Each of them had thought that her problems were entirely mental. Although she had “been 39 for several years,” she was slender and smart, and she knew that she was attractive to men.

She intended to stay that way. Her job as personal secretary to the chairman of the department of English and literature at a large Midwestern university introduced her to a lot of eligible males. And that was where Lisa first noticed the problem that made her think she was losing her mind.

“It was this gorgeous assistant professor of Romance languages,” she told the interviewer. “He was always in and out of the office, and I’d done everything short of sexual harassment to get him to notice me. Then one day last spring, he asked me out to dinner and a show. And I turned him down! I just wasn’t interested. It was as if my sex drive had gone on sabbatical!”

For several weeks she continued to feel uninterested in men, and then one morning she “woke up next to some odious creep from the provost’s office” she’d been avoiding for months. She felt disgusted with herself, but they had sex again anyway, before she kicked him out.

For the next several months, Lisa’s sexual appetite would suddenly change every 2 or 3 weeks. Privately, she had begun to call it “The Turn of the Screw.” During her active phase, she felt airy and light, and could pound away on her computer 12 hours a day. But the rest of the time, nothing pleased her. She was depressed and grouchy at the office, slept badly (and alone), and joked that her keyboard and mouse were conspiring to make her feel clumsy.

Even Lisa’s wrists felt weak. She had bought a wrist rest to use when she was typing, and that helped for a while. But she could find neither splint nor tonic for the fluctuations of her sex drive. One doctor told her it was “the change” and prescribed estrogen; another diagnosed “manic–depression” and offered lithium. A third suggested pastoral counseling, but instead she had come to the clinic.

In frustration, Lisa arose from her chair and paced to the window and back.

“Wait a minute—do that again,” the interviewer ordered.

“Do what? All I did was walk across the room.”

“I know. How long have you had that limp?”

“I don’t know. Not long, I guess. What with the other problems, I hardly noticed. Does it matter?”

It proved to be the key. Three visits to a neurologist, some X-rays, and an MRI later, Lisa’s diagnosis was multiple sclerosis. The neurologist explained that multiple sclerosis sometimes caused mood swings; treatment for it was instituted, and Lisa was referred back to the mental health clinic for psychotherapy.

Evaluation of Lisa Voorhees

On paper, the various criteria sets make reasonably clear-cut the differences between mood disorders with “emotional” causes and those caused by general medical conditions or substance use. In practice, it isn’t always obvious.

Lisa’s mood symptoms alternated between periods of highs and lows. Although they lasted 2 weeks or longer, none of these extremes was severe enough to qualify as a manic, hypomanic, or major depressive episode. The depressed period was too brief for dysthymia; the whole episode had not lasted long enough for cyclothymic disorder; and there was no evidence of a substance-induced mood disorder.

Depressive (or bipolar) disorder due to another medical condition must fulfill two important criteria. The first is that symptoms must be directly produced by physiological mechanisms of the illness itself, not simply by an emotional reaction to having the illness. For example, patients with cancer of the head of the pancreas are known to have a special risk of depression, which doesn’t occur just as a reaction to the news or continuing stress of having a serious medical problem.

Several lines of evidence could bear on a causal relationship between a medical condition and mood symptoms. A connection may exist if the mood disorder is more severe than the general medical symptoms seem to warrant or than the psychological impact would be on most people. However, such a connection would not be presumed if the mood symptoms begin before the patient learns of the general medical condition. Similar mood symptoms developing upon the disclosure of a different medical problem would argue against a diagnosis of either bipolar or depressive disorder due to another medical condition. By contrast, arguing for a connection would be clinical features different from those usual for a primary mood disorder (such as atypical age of onset). None of these conditions obtained in the case of Lisa Voorhees.

A known pathological mechanism that can explain the development of the mood symptoms in physiological terms obviously argues strongly in favor of a causal relationship. Multiple sclerosis, affecting many areas of the brain, would appear to satisfy this criterion. A high percentage of patients with multiple sclerosis have reported mood swings. Periods of euphoria have also been reported in these patients; anxiety may be more common still.

Many other medical conditions can cause depression. Endocrine disorders are important causes: Hypothyroidism and hypoadrenocorticalism are associated with depressive symptoms, whereas hyperthyroidism and hyperadrenocorticalism are linked with manic or hypomanic symptoms. Infectious diseases can cause depressive symptoms (many otherwise normal people have noted lassitude and low mood when suffering from a bout of the flu; Lyme disease has been getting a lot of attention recently). Space-occupying lesions of the brain (tumors and abscesses) have also been associated with depressive symptoms, as have vitamin deficiencies. Finally, about one-third of patients with Alzheimer’s disease, Huntington’s disease, and stroke may develop serious depressive symptoms.

The second major criterion for a mood disorder due to another medical condition is that the mood symptoms must not occur only during the course of a delirium. Delirious patients can have difficulties with memory, concentration, lack of interest, episodes of tearfulness, and frank depression that closely resemble major depressive disorder. Lisa presented no evidence that suggested delirium.

As to the specifier, we could choose between with manic features and with mixed features (see Essential Features, above). At different times, Lisa had both extremes of mood; neither predominated, so I’d go with . . . well, see below, along with a GAF score of 70. The code and name of the general medical condition would be included, as follows, with the name of the medical condition:

Mood Disorders Due to Another Medical Condition