OTHER SPECIFIED AND UNSPECIFIED MOOD DISORDERS

OTHER SPECIFIED AND UNSPECIFIED MOOD DISORDERS

OTHER SPECIFIED AND UNSPECIFIED MOOD DISORDERS

F31.89 [296.89] Other Specified Bipolar and Related Disorder

Use other specified bipolar and related disorder when you want to write down the specific reason your patient cannot receive a more definite bipolar diagnosis. To prevent overuse and “medicalization” of the normal ebb and flow of mood, the patient must have symptoms that don’t qualify for a more specific bipolar disorder diagnosis and that cause distress or interfere with the patient’s normal functioning. DSM-5 gives a number of examples:

Short-duration hypomanic episodes (2–3 days) and major depressive episodes. Such a patient will have had at least one fully qualified major depressive episode, plus at least one episode of hypomania too brief (2–3 days) to justify a diagnosis of bipolar II disorder. Because the depression and hypomania don’t occur together, a with mixed features designation wouldn’t be appropriate.

ORDER COMPREHENSIVE SOLUTION PAPERS ON OTHER SPECIFIED AND UNSPECIFIED MOOD DISORDERS

Hypomanic episodes with insufficient symptoms and major depressive episodes. Such a patient will have had least one major depressive episode but no actual manic or hypomanic episodes, though there will have been at least one episode of subthreshold hypomania. That is, the high phase is long enough (4 days or more) but is a symptom or two shy of the number required for a hypomanic episode (elevated mood plus one or two of the other symptoms of a hypomanic episode, or irritable mood plus two or three of the other symptoms of hypomania). The hypomanic and major depressive symptoms don’t overlap, so you can’t call it major depressive episode with mixed features.

Hypomanic episode without prior major depressive episode. Here you’d classify (no surprise) someone who has had an episode of hypomania but who hasn’t ever fully met criteria for a major depressive episode or a manic episode.

Short-duration cyclothymia. In a period less than 2 years (less than 12 months for a child or adolescent), such a patient will have had multiple episodes of both hypomanic symptoms and depressive symptoms, all of which will have been either too brief or have too few symptoms to qualify for a major depressive or hypomanic episode. Of course, there will be no manias and no symptoms of psychosis. Patients with short-duration cyclothymia will have symptoms for a majority of days and will have no symptom-free periods longer than 2 months.

Note that DSM-5 cautions us not to use just other specified bipolar disorder or other specified depressive disorder as the actual diagnosis. Rather, we are also supposed to state, in full, one of the many (often cumbersome) titles given in the bipolar list just above and the depressive list below. One thing is certain: Regardless of which of the several discrete terms we choose, there is just one code number for each of these two categories of uncertainty.

F31.9 [296.80] Unspecified Bipolar and Related Disorder

And here you’d include patients for whom you don’t care to indicate the reason you aren’t diagnosing a well-defined bipolar condition.

F32.8 [311] Other Specified Depressive Disorder

Use other specified depressive disorder in the same way as described above for other specified bipolar and related disorder. DSM-5 provides the following examples of other specified depressive disorder:

Recurrent brief depression. Every month for 12+ months, lasting from 2 to 13 days at a time, these patients have low mood plus at least four other symptoms of depression that aren’t associated with menstruation. The patients have never fulfilled criteria for another mood disorder, and they’ve not been psychotic.

Short-duration depressive episode. These patients would meet criteria for major depressive episode except for duration—their episodes last 4–13 days. Here’s the full run-down: depressed mood; at least four other major depressive symptoms; clinically significant distress or impairment; have never met criteria for other mood disorders; not currently psychotic; and don’t meet criteria for other conditions.

Depressive episode with insufficient symptoms. These patients would meet criteria (duration, distress) for major depression, except that they have too few symptoms. They don’t have another psychotic or mood disorder.

F32.9 [311] Unspecified Depressive Disorder

As for unspecified bipolar and related disorder, when you don’t care to indicate the reason for a more secure diagnosis, you can use the unspecified depressive disorder category. The advantage: mood disorders “of uncertain etiology” have been used so often in the past as to undermine their value.

Whenever we clinicians encounter a patient with schizophrenia and postpsychotic depressive disorder, or one with a major depressive episode superimposed on a psychosis, we should think extra carefully about the diagnosis. Likewise, the occurrence of a manic episode in a patient who was formerly diagnosed as psychotic should cause us to wonder whether the original diagnosis was correct. In both cases, some of these patients may actually have bipolar I disorder, and not schizophrenia or another psychotic disorder at all. This would appear to be an ongoing problem, regardless of which edition of the DSM we are using.

*I suppose it’s possible that a patient with bipolar II disorder might end up hospitalized without really needing it. In that case, I’d go with the predominant symptoms and call it bipolar II.