Mood Disorders

1. Introduction to the Mood Disorders

  • A mood disorder is a pattern of illness due to an abnormal mood. Nearly every patient who has a mood disorder experiences the "lows" of depression at some time, but some may also have the "highs" of mania. Many, but not all, mood disorders are diagnosed on the basis of a mood episode. Most patients with mood disorders will fit into one of the codeable categories listed below.
  • Mood disorders in general are quite prevalent with about 1 in 10 being affected. Depression is real and it is serious. It's more than "having a bad day." Depressed individuals can't simply wake up one day and "shake it off." It is a medical condition every bit as serious as any other medical condition and should be treated as such.
  • "Mood" should not be confused with "affect," as they are two different things defined separately in the DSM-IV-TR. The DSM-IV-TR defines the two as affect being "...the subjective or expression of a feeling state (emotion)...in contrast to mood, which refers to a more pervasive and sustained emotional 'climate,'affect refers to more fluctuating changes in emotional 'weather.' The person may be unaffected by happy moods, and just stay in a state of sorrow. Their mood will not lift, no matter who is around them. They are emotionally unresponsive.
  • Mood disorders pertain to both unipolar and bipolar disorders. Most are correlated with a mania and a depressive mood.
    • In unipolar disorders, the patient suffers from only severe depression. The person usually is on the low end of sad and depressed states of their mood.
    • In bipolar disorders, the person experiences both manic highs and depressive lows.
  • Certain prescription drugs can lead to mood disorders. These prescription drugs include: corticosteroids, levodopa (Parcopa and other drugs used to treat Parkinson’s disease), and methylphenidate (Ritalin and others, commonly used for treating attention deficit disorder) can trigger mania in bipolar disorder (2009). Other drugs, including some used to treat high blood pressure and cancer, have been known to cause depression. Prescription drugs do have side effects but unfortunately they can lead to mood changes as well. Brain trauma in an individual can lead to a alteration in a person’s mood (2009). Mood disorders are difficult to detect in milder forms because there is no blood or laboratory tests (2009).
  • Links





2. Major Depressive Episode

    • DSM-IV-TR criteria
      • A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure
        • NOTE: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations
        1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). NOTE: In children and adolescents, can be irritable mood.
        2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
        3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. NOTE: In children, consider failure to make expected weight gains.
        4. Insomnia or hypersomnia nearly every day
        5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
        6. Fatigue or loss of energy nearly every day
        7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
        8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
        9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicid
      • B. The symptoms do not meet criteria for a Mixed Episode
      • C. the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
      • D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism)
      • E. The symptoms are not better accounted for by Bereavement, i.d., after the loss of a loved one; the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness suicidal ideation, psychotic symptoms, or psychomotor retardation.
    • Associated features
      • The individual must have experienced at least one Major Depressive Episode in the absence of any history of manic episodes. Individuals with Major Depressive Episode show irritability, anxiety, phobias, worry over physical health, and complaints of pain.
      • Postpartum depression can precipitate a Major Depressive Episode.
      • Often experience tearfulness, irritability, brooding, obsessive rumination (thinking very deeply about something), anxiety, phobias, worry about health, and complaints of pain. Panic attacks are seen during some Major Depressive Episodes. Issues with close relationships, sexual functioning, and problems maintaining relationships/marriages. Occupational and academic problems may result from a Major Depressive Episode. Suicide risk is higher in individuals with Major Depressive Episodes, especially if they present psychotic features. Sleep abnormalities are seen in 40 to 60 percent of outpatients with a Major Depressive Episode, and 90 percent of inpatients.
    • Child vs. adult presentation
      • Core symptoms are the same for children and adolescents, although data suggests that the prominence of characteristic symptoms may change with age.
      • Children will experience separation anxiety more than adults.
      • The main symptoms of Major Depressive Episodes are the same in adults and children, but the presentation of symptoms may change with age.
      • Certain symptoms such as somatic complaints, irritability, and social withdrawal are particularly common in children, whereas psychomotor retardation, hypersomnia, and delusions are less common in prepuberty than in adolescence and adulthood. In prepubescent children, Major Depressive Episodes occur more frequently in conjunction with other mental disorders (especially Disruptive Behavior Disorders, Attention-Deficit Disorders, and Anxiety Disorders) than in isolation. In adolescents, Major Depressive Episodes are frequently associated with Disruptive Behavior Disorders, Attention-Deficit Disorders, Anxiety Disorders, Substance-Related Disorders, and Eating Disorders. In elderly adults, cognitive symptoms (e.g., disorientation, memory loss, and distractibility) may be particularly prominent.
    • Gender and cultural differences in presentation
      • Culture can influence the experience and communication of symptoms of depression. Underdiagnosis or misdiagnosis can be reduced by being alert to ethnic and cultural specificity in presenting complaints of a Major Depressive Episode. For example, in some cultures, depression may be experienced largely in somatic terms, rather than with sadness or guilt. Complaints of "nerves" and headaches (in Latino and Mediterranean cultures), weakness, tiredness, or "imbalance" (in Chinese and Asian cultures), problems of the "heart" (in Middle Eastern cultures), or of being "heart-broken" (among Hopi) may express the depressive experience. Such presentations combine features of the Depressive, Anxiety, and Somatoform Disorders. Cultures may also differ in judgments about the seriousness of experiencing or expressing dysphoria. Culturally distinctive experiences (e.g., fear of being hexed or bewitched, feelings of "heat in the head" or crawling sensations of worms or ants, or vivid feelings of being visited by those who have died) must be distinguished from actual hallucinations or delusions that may be part of a Major Depressive Episode, With Psychotic Features. It is also imperative that the clinician not routinely dismiss a symptom merely because it is viewed as the "norm" for a culture.
      • Women are at significantly greater risk than men to develop Major Depressive Episodes at some point during their lives, with the greatest differences found in studies conducted in the United States and Europe. This increased risk emerges during adolescence and may coincide with the onset of puberty. Thereafter, a significant proportion of women report a worsening of the symptoms of a Major Depressive Episode several days before the onset of menses. Women are especially vulnerable to depression after giving birth. This is a result of hormonal and physical changes. Although new mothers commonly experience temporary "blues," depression that lasts longer than 2 - 3 weeks is not normal and requires treatment.
      • Some theorists believe that the reason minorities have differing rates of depressive disorder is that symptoms of depression are presented differently than Caucasians.
      • Men are more likely to successfully complete suicide during depression than women. Mainly because men will take more drastic measures (such as a gun, hanging, jumping, etc) whereas women will be more likely to cut their wrists the wrong way or take pills.
    • Epidemiology
      • Studies indicate that depressive episodes occur twice as frequently in women as in men.
      • A Cross-national synthesis of epidemiology evidence on major depressive disorders was done by the World Health Organization Composite International Diagnostic Interview and administered face-to-face in 10 different countries. They found that in a range of 40% to 55% in a 12 month to lifetime prevalence compared with a 30 day to 12 month prevalence of 45% to 65% where the consistent socio-demographic correlates in that being female and unmarried has a higher rate for major depression. Also, if the person has other disorders for a long period of time then the likelihood gets higher.
    • Etiology
      • Stressful life situations can contribute to the onset of symptoms of major depression, most of the time these events involve some type of loss. There are also several different biological and neural bases that can contribute to the development of major depression. There is evidence of abnormalities in brain regions such as the thalamus, cortex, and cerebellum among others. Problems such as the increased size of cerebral ventricles may cause the loss of neural tissues. Abnormal dopamine, norepinephrine, and serotonin neurotransmitters are also considered potential causes of major depression. It is also believed that some genes are components in the cause of major depressive episodes.
    • Empirically supported treatments
      • Both medication and psychotherapy can be used to treat depression. Antidepressants are usually more effective in those with major depression, but psychotherapy can be effective in addition to these medications. CBT, or cognitive behavioral therapy, focuses on the relationship between events and emotions and helps patients with stress, social skills, and activities training.
      • Other forms of treatment include psychotherapy, and shock therapy. Medication wise, drugs like the SSRIs (selective serotonin reuptake inhibitors), Atypical antidepressants (non-SSRIs), TCAs (tricyclic antidepressants), and MAOIs (monoamine ocidase inhibitors) are often presribed. These drugs can often take up to two months to become effective so the soon the treatment is started, the better. Antidepressants increase the levels of the "feel good" chemicals in the brain (serotonin, dopamine, etc).
      • Antidepressant medications have just as many side effects as the next drug. Patients may encounter several effects including sexual side effects (decreased libido) , appetite changes, blurred vision, dry mouth, and others depending on the type and brand of drug.

  • Abraham Lincoln, one of the most well-known presidents, had major depression despite the fact that he was a renowned jokester.
Links
Drugs Treatments for Depression
Additional Information:

Depression affects individuals differently and has a spectrum of levels of depression. People who struggle with severe depression have trouble getting out of bed in the morning, socializing, and going to work (2009).

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3. Manic Episode



    • DSM-IV-TR criteria
      • A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
      • B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
        1. inflated self-esteem or grandiosity
        2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
        3. more talkative than usual or pressure to keep talking
        4. flight of ideas or subjective experience that thoughts are racing
        5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
        6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
        7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
      • C. Mood disturbance is severe enough to cause marked impairment in occupational function, social activities, or relationships, or severe enough to necessitate hospitalization to prevent harm to self or to others.
      • D. At no time have delusions or hallucinations been present for two weeks in the absence of prominent mood symptoms.
      • E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hypothyroidism)
      • F. No organic factor is known that initiated or maintained the disturbance.
        • NOTE: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.
    • Associated features
      • Many individuals do not realize that they are ill and will resist to be treated. They become impulsive in decisions and will chose to be somewhere that is nowhere near any relatives or those that they are in close relationship. They sometimes choose to change their physical appearance to be appealing (that is out of character) to the opposite sex. Individuals may become more sexually active (hypersexuality). They may become involved in activities in a strange way (giving candy,money,or advice to complete strangers). They may involve themselves in foolish unethical impulses such as claiming the victory in something that was not theirs to begin with. They may become hostile, threaten or physically assault others, or suicidal.
      • His/her mood may quickly move from anger to depression. The more that Manic develops the more likely that they will increase the amount of stimulants that they use and will prolong the episode.
      • In the Manic Episodes it may involve the norepinephrine, serotonins, acetycholine, dopamine, or gamma-aminobutyric acid neurotransmitters systems in some abnormality.
      • When they have delusions and hallucinations they are mood-congruent. For example a person with a elated mood may think or believe he has special powers.
      • Many manic depressive episodes may be trigged by the following: fatigue, medications, alcohol, drug abuse, and stress
    • Child vs. adult presentation
      • Manic episodes in adolescents are more likely to include psychotic features and may be associated with school truancy, antisocial behavior, school failure, or substance abuse that is in social situations. A significant minority of adolescents appear to have a history of long-standing behavior problems that precede the onset of a frank Manic Episode. It is unclear whether these problems represent a prolonged prodrome to Bipolar Disorder or an independent disorder.
    • Gender and cultural differences in presentation
      • It affects people in all race categories from Caucasians to Asians.
      • Latinos and Mediterranean cultures complain about nerves and headaches.
      • Chinese and Asian cultures complain about weakness, tiredness, or imbalance.
      • Middle Eastern cultures complain about problems of the heart or heartbreak.
    • Epidemiology
      • In many instances (50-60%), a Major Depressive Episode immediately precedes or immediately follows a Manic Episode, with no intervening period of euthymia. It should be noted that the causes of the episodes should not be better accounted by, or completely caused by things such as medications/substances or other medical conditions.
    • Etiology
      • The mean age of onset is the early 20's, but some cases start in adolescents and others start after age 50. Manic episodes typically begin suddenly, with a rapid escalation of symptoms over a few days. Frequently, episodes occur following psychosocial stressors. Manic Episodes usually last from a few weeks to several months and are briefer and end more abruptly than Major Depressive Episodes.
      • Manic Depression can also be recognized as Bipolar Disorder based on the sudden/dramatic mood swings that can change at any moment or time.
    • Empirically supported treatments
      • Valproate has been known to be effective in treating acute mania and has sedative properties. It has a response rate of 2/3. Atypical antipsychotics can also be a useful alternative since these drugs typically have reasonably short negative side effects. Clonazepam and Lorazepam can be used for patients that are agitated or overactive to make sure they get some sleep.

  • Manic depressives may be triggered by a change in the seasons. The summer months is more common for episodes of mania.
    • Draft Criteria for Bipolar I Disorder- Retain structure, with changes limited to the definitions of mood episodes that define each.
    • Diagnostic criteria for Bipolar I Disorder, Most Recent Episode Manic
      1. Currently (or most recently) in a Manic Episode (see Criteria for Manic Episode).
      2. There has previously been at least one Major Depressive Episode (see Criteria for Major Depressive Episode), Manic Episode (see Criteria for Manic Episode), or Mixed Episode (see Criteria for Mixed__Specifier__).
      3. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specifiers and/or current features have not yet been reviewed by the Workgroup for bipolar disorder. It is anticipated that specifiers and/or features that apply across the mood disorders will be consistent across major depression and bipolar disorder. The bipolar specific rapid cycling specifier is under review to consider whether to keep as is, eliminate, or modify

Additional Information:

Impulsivity is a prominent component of the manic syndrome, so manic features during depressive syndromes may be associated with impulsivity and its consequences, including increased risk of substance abuse and suicidal behavior (Swann, Gerard, Steinberg, Schneider, Barrattt, & Dougherty, 2007). Manic episodes can be mild but are usually quite common in bipolar disorder. The findings indicated that long term depressed patients with manic symptoms susceptibility to impulsivity (Swann, et al., 2007). This usually included patients who had a history of alcohol abuse, head trauma, and suicide attempts. “The results showed that the presence of manic symptoms during depressive episodes was related to greater current and lifetime behavioral risk. Manic symptoms appear to be a dimensional component of bipolar depressive episodes, but may have a threshold of severity associated with increased impulsivity and associated behavioral risks. This may reflect a combination of depression with trait impulsivity. While manic symptoms were associated with more severe previous complications, their predictive value, and the validity of a subtype of depression defined on the basis of manic symptoms, must be confirmed prospectively (Swann, et al., 2007).”

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4. Mixed Episode


    • DSM-IV-TR criteria
      • A. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.
      • B. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or there are psychotic features.
      • C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
        • NOTE: Mixed-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electro-convulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.
    • Associated features
      • Individuals may have disorganized thoughts or behavior. They may also experience dysphoria, or a sense of good feeling and in a daze. These individuals may be more likely to seek out for help. They also have similar features found in severe Major Depressive episodes such as experiencing manic episodes.
    • Child vs. adult presentation
      • Mixed episodes appear to be more common in younger individuals and in individuals over age 60 years with Bipolar I Disorder and may be more common in males than in females.
    • Gender and cultural differences in presentation
      • It affects all races.
      • Latinos and Mediterranean cultures complain about nerves and headaches.
      • Chinese and Asian cultures complain about weakness, tiredness, or imbalance.
      • Middle Eastern cultures complain about problems of the heart or heartbreak.
      • May be more common in males than females
      • Males tend to report experiencing manic symptoms first, while women report feeling the depressive symptoms.
    • Epidemiology
      • There is evidence of this disorder in no more than 1% of the general population, and even less in clinical settings where the ones remitted to the population is a very small percentage in the clinical population of patients.
    • Etiology
      • Features are similar to those for Manic Episodes and Major Depressive Episodes. Individuals may be disorganized in their thinking or behavior. Because individuals in Mixed Episodes experience more dysphoria than do those in manic Episodes, they may be more likely to seek help.
      • Laboratory findings for Mixed Episode are not well studied, although evidence to date suggests physiological and endocrine findings that are similar to those found in severe Major Depressive Episodes.
      • Mixed episodes, according to the DSM, require a full mania and full depresssion, psychiatrists use the term mixed episode to define this term.
    • Empirically supported treatments
      • The first step that must be taken is a accurate diagnosis. Here therapists should assess for comorbidities and make clear the targets that need to be further examined during therapy. Typically antipsychotics or divalproex have been shown to be effective. Most therapists try to avoid the use of antidepressants.
  • DSM-V
    • From the DSM-IV, Mixed-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.
    • The MIxed Episode will be replaced with Mixed features specifier.
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5. Hypomanic Episode


    • DSM-IV-TR criteria
      • A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non-depressed mood. It is characterized as a period of increased energy that is not sufficient or severe enough to qualify as a Manic Episode.
      • B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
        1. inflated self-esteem or grandiosity
        2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
        3. more talkative than usual or pressure to keep talking
        4. flight of ideas or subjective experience that thoughts are racing
        5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
        6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
        7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments
      • C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic
      • D. The disturbance in mood and the change in functioning are observable by others.
      • E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
      • F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism)
        • NOTE: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder.
    • Associated features
      • It has similar features as Manic Episode. Their mood may be described as irritable or depressive in a clinical setting.
      • Along with clinical features may include tearfulness, anxiety, obsessive ruminations, panic attacks, and lots of health concerns.
    • Child vs. adult presentation
      • In younger persons, hypomanic Episodes may be associated with school truancy, antisocial behavior, school failure, or substance use. With adults, hypomanic episodes may be associated with work, family or marital issues, and other stress related situations. The symptoms are the same in presentation, but what causes the hypomanic episodes may be different with children than adults.
    • Gender and cultural differences in presentation
      • It affects individuals in all race categories.
      • Latinos and Mediterranean cultures complain about nerves and headaches.
      • Chinese and Asian cultures complain about weakness, tiredness, or imbalance.
      • Middle Eastern cultures complain about problems of the heart or heartbreak.
    • Epidemiology
      • 5%-15% of individuals with hypo-mania will ultimately develop a Manic Episode.
    • Etiology
      • Episodes usually begin suddenly, with a quick escalation of symptoms that occur within a day or so. Episodes may last for several weeks to months and are usually more brief and abrupt in onset than Major Depressive Episodes. In many cases, the Hypomanic Episode may be preceded or followed by a Major Depressive Episode.
    • Empirically supported treatments
      • Patients with Hypo-manic episodes will usually be prescribed medication to help eliminate or dull down the symptoms. Some common medications are mood stabilizers such as valproic acid and lithium carbonate. Atypical antipsychotics may also be used such as olanzopine and quetiapine. Besides using medications, there is not much information about alternative treatment methods.
    • Most Recent Episode Hypomaniac- in Bipolar I Disorder in the DSM-V
      • Draft criteria for Bipolar I Disorder- Retain structure, with changes limited to the definitions of mood episodes that define each.
      • Diagnostic Criteria for Bipolar I Disorder, Most Recent Episode Hypomanic
        A. Currently (or most recently) in a Hypomanic Episode (see __Criteria for Hypomanic Episode__).
        B. There has previously been at least one Manic Episode (see
        __Criteria for Manic Episode__).

        C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
        D. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

        Specifiers and/or current features have not yet been reviewed by the Workgroup for bipolar disorder. It is anticipated that specifiers and/or features that apply across the mood disorders will be consistent across major depression and bipolar disorder. The bipolar specific rapid cycling specifier is under review to consider whether to keep as is, eliminate, or modify.

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6. Major Depressive Disorder (296.xx)


    • DSM-IV-TR criteria
      • 296.2x Major Depressive Disorder, Single Episode
        • A. Presence of a single Major Depressive Episode and a Unipolar disorder.
        • B. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
        • C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. NOTE: This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition.
        • It is important to maintain a healthy lifestyle to avoid major depressive disorder in the following: avoid drugs and alcohol, eat well balanced meals, get regular sleep and exercise, and seek supportive relationships. This might seem like simple tasks to obtain, but for many each one might be an obstacle.
        • If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or features:
          • Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features
          • Chronic
          • With Catatonic Features
          • With Melancholic Features
          • With Atypical Features
          • With Postpartum Onset
        • Beck's Depression Scale Inventory or other screening tests for depression can be helpful in making the diagnosis. More information available at:Becks Depression Scale
        • If the full criteria are not currently met for a Major Depressive Episode, specify the current clinical status of the Major Depressive Disorder or features of the most recent episode:
          • In Partial Remission, In Full Remission
          • Chronic
          • With Catatonic Features
          • With Melancholic Features
          • With Atypical Features
          • With Postpartum Onset
      • 296.3x Major Depressive Disorder, Recurrent
        • A. Presence of two or more Major Depressive Episodes
          • NOTE: To be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are not met for a Major Depressive Episode.
        • B. The Major Depressive Episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
        • C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. NOTE: This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition.
        • If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or features:
          • Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features
          • Chronic
          • With Catatonic Features
          • With Melancholic Features
          • With Atypical Features
          • With Postpartum Onset
        • If the full criteria are not currently met for a Major Depressive Episode, specify the current clinical status of the Major Depressive Disorder or features of the most recent episode:
          • In Partial Remission, In Full Remission
          • Chronic
          • With Catatonic Features
          • With Melancholic Features
          • With Atypical Features
          • With Postpartum Onset
        • Specify:
          • Longitudinal Course Specifiers (With and Without Interepisode Recovery)
          • With Seasonal Pattern
    • Associated features
      • Most people complain most about a sad mood that won’t go away. People that have MDD, experience a low mood over several days or weeks. Some of the symptoms are: depressed mood, loss of interest in pleasurable activities, change in appetite, insomnia, psychomotor retardation, and sense of worthlessness or guilt, problems with clear thinking or concentration, thoughts of death or suicide, etc. ”Depressed children often display an irritable rather than a depressed mood, and show varying symptoms depending on age and situation. Most show a loss of interest in school and a decline in academic performance. They may be described as clingy, demanding, dependent, or insecure. Diagnosis may be delayed or missed when symptoms are interpreted as normal moodiness.” The appetite tends to fluctuate. Individuals with this disorder may engage in "comfort eating," and thus gain weight. The comfort foods they choose are are easy to eat and are often addictive.
      • Major Depressive Disorder often co-exists with other disorders. The National Comorbidity Survey reports that 51% of people with MDD also suffer from anxiety. Anxiety symptoms can delay recovery, have an increased risk of relapse and an increase in suicide attempts. Also, increased reports of alcohol and drug abuse exist. Attention Deficit Hyper-activity Disorder and Post Traumatic Stress Disorder are also often comorbid with MDD. Anhedonia is often expressed which means a significantly decreased interest or pleasure in all activities most of the day. The change in appetite is usually varies from significant weight gain, a considerable decrease in food consumption, or everyday variation basis.
    • Child vs. adult presentation
      • In childhood, boys and girls can be equally affected. But in adolescence and adulthood, it occurs twice as often in women than in males.
      • The symptoms are the same in children and adults but the characteristic of the symptoms change.
      • Children are usually associated with irritability and social withdrawal.
      • Elderly are usually associated with disorientation, memory loss, and distractibility.
    • Gender and cultural differences in presentation
      • It affects all races.
      • Latinos and Mediterranean cultures complain about nerves and headaches.
      • Chinese and Asian cultures complain about weakness, tiredness, or imbalance.
      • Middle Eastern cultures complain about problems of the heart or heartbreak.
    • Epidemiology
      • MDD is a very common condition. In the United States, 17.1% of people will experience at least one episode of MDD in their lifetime. Worldwide, it ranges from about 8-12%. Only 4.9% of the general population actually meets the DSM-IV criteria to be diagnosed with MDD. It is known to happen more to women than in men for reasons that are unknown. Before puberty, there is really no difference between the prevalence in males and females. It is documented that people commonly develop MDD in their late adolescence or early adulthood.
      • The lifetime prevalence for men and women vary in the general population. For women it is 10% to 25% and for men it is 5% to 12%. The prevalence rates are not prejudice in any way. It affects all races, sex, education, and income levels.
    • Etiology
      • Major Depressive Disorder seems to be highly inheritable. Researchers have studied twins, and found strong genetic influence in depression. Identical twins that were raised in the same environment have about a 50% chance of both developing depression whereas, fraternal twins that were raised in the same environment only have about a 20% chance of developing depression. Adoption studies have also been influences in determining whether depression is genetic. Researchers have found that children of depression are more susceptible to depression even when adopted. Environmental factors have also been known to influence depression. Early stressful life events can make children more prone to developing depression later on in life. Such as losing a parent, sibling or relative or parents getting divorced, etc. Other environmental factors include low socioeconomic status and/or frustrating or unpleasant relationships.
    • Empirically supported treatments
      • Successful treatment of patients with major depressive disorder is promoted by a complete assessment of the patient. Treatment generally consists of three phases: an acute phase, a continuation phase, and a maintenance phase. Psychiatrists treating patients suffering from this disorder often use a variety of medications, psychotherapeutic approaches, electroconvulsive therapy, and other treatments methods, such as light therapy. Regardless of the specific treatment selected, it is important that the patient is provided with psychiatric management throughout each phase of the treatment.
      • Medications include tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin re-uptake inhibitors (SSRIs), and some newer antidepressant drugs. Although antidepressant medications can be very effective, some may not be appropriate for everyone. For example, in 2007, the FDA proposed that all antidepressant medicines should warn of the risk of suicidal behavior in young adults ages 18 - 24 years. Lithium and thyroid supplements may be needed to enhance the effectiveness of antidepressants. People with psychotic symptoms, such as delusions or hallucinations, may need antipsychotic medications.
      • Antidepressant medications are often used as an initial primary treatment for mild major depressive disorder and psychotherapy alone is also used as an initial treatment for patients with mild to moderate major depressive disorder. A combination of psychotherapy and medication may also be used as an initial treatment for patients with psychosocial issues, interpersonal problems or a comorbid axis II disorder with moderate to severe major depressive disorder. Most people benefit with a combination of the two treatments. Lastly, electroconvulsive therapy can be used for patients with major depressive disorder with a high degree of severe symptoms or in patients in which psychotic symptoms or catatonia are present.
    • Most Recent Episode Depressed
      • Draft Criteria for Bipolar I Disorder- Retain structure, with changes limited to the definitions of mood episodes that define each.
    • Diagnostic criteria for Bipolar I Disorder, Most Recent Episode Depressed
      1. Currently (or most recently) in a Major Depressive Episode (see Criteria for Major Depressive Episode).
      2. There has previously been at least one Manic Episode (see Criteria for Manic Episode).
      3. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
  • Specifiers and/or current features have not yet been reviewed by the Workgroup for bipolar disorder. It is anticipated that specifiers and/or features that apply across the mood disorders will be consistent across major depression and bipolar disorder. The bipolar specific rapid cycling specifier is under review to consider whether to keep as is, eliminate, or modify
    the Bipolar Subworkgroup will maintain whatever definition of MDE is finalized by the MDD Subworkgroup, with the exception that our review of the literature suggests the need to recognize the subgroup of those with MDE and mixed (i.e. manic/hypomanic) features.
    Links
  • http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=6&hid=13&sid=baf65d19-fe39-421e-b023-99de13dbbeb0%40sessionmgr12
    http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=7&hid=13&sid=baf65d19-fe39-421e-b023-99de13dbbeb0%40sessionmgr12
  • NIMHgov: Depression - http://www.youtube.com/watch?v=mlNCavst2EU

  • Additional Information
    • Finding of this study was that there does appear to be a discernable prodromal phase to depressive episodes as well as several symptoms that appear to be common to the depressive prodrome across individuals (Iacoviello, Alloy, Abramson, & Choi, 2010). A prodromal phase is a clear deterioration in function before the active phase of a mental disturbance. It is not caused by a disorder in mood or a psychoactive substance and includes some residual phase symptoms (Iacoviello, et al., 2010). There were seven symptoms that were included: sad mood, decreased interest in or pleasure from activities, difficulty concentrating, hopelessness, worrying/brooding, decreased self-esteem, and irritability. These symptoms tended to be present in the prodromal phase and also could serve as warning signs that lead to an acute episode of depression (Iacoviello, et al., 2010).
    • Cognitive behavioral therapy is an empirically supported type of treatment that focuses on maladaptive ways of thinking and why people think the way they do (Warman & Beck, 2003). Cognitive behavioral therapy is said to be a successful form of treatment for individuals with major depressive disorder.
      • In a study by Carlbring and colleagues (2009) conducted a study using an online form of cognitive behavioral therapy and results indicate that cognitive behavioral therapy is an effective type of treatment for individuals suffering from major depressive disorder when therapist interaction, through email and other forms of communication, was involved. Individuals participating in this study rated therapists on several different measures and results concluded that when asked about life satisfaction, all participants showed improvement which was shown by significant amounts of clustering of therapists data. This study is an example of how cognitive behavioral therapy can be effective is combined with communication to help individuals with major depressive disorder.
      • Research conducted by de Graaf, Hollon, and Huibers (2010) examined the short-term improvements of individuals with depression who used computerized cognitive behavioral therapy as a treatment for their depression. Individuals were divided into three groups; one group used the computerized cognitive behavioral approach only, the second used both CBT and regularly prescribed treatments, and the third group only used regular treatments. Results indicated that after 12 months, those individuals with high optimism improved using only the CBT approach, while those needing more support improved using both CBT and regular treatment. In most instances, individuals with mild to moderate depression gain the most benefits from cognitive behavioral therapies, but it is possible in some cases for individuals with severe depression to also benefit from computerized cognitive behavioral therapy. This research provides an example of the effective use of cognitive behavioral therapy as a means to improve symptoms of people suffering from depression.
      • Stuhlmiller and Tolchard (2009) make the argument, in their research, that computerized cognitive behavioral therapy is just a effective as other forms of cognitive behavioral therapies, but is less expensive, easy to teach, and more readily accessible to patients. Using technology and other tools that are easily accessible to individuals suffering from depression may result in cognitive behavioral therapy being more beneficial and used by more individuals.
      • According to Jungbluth and Shirk (2009), incorporating cognitive behavioral therapy in group counseling sessions that consist of adolescents with treatment-resistant depression, may result in several positive outcomes. Conclusions from research indicate that patient involvement and overall social functioning both show improvements as result of a cognitive behavioral approach. Research conducted by Matsunaga and colleagues (2010) also supports the results from the previous study that cognitive behavioral therapy can improve social functioning when added to a treatment plan for individuals with treatment-resistant depression.
      • Another study conducted by Kennard and colleagues (2009) also explored the effects of cognitive behavioral therapy in adolescents with depression. This particular research examined the effects of combining cognitive behavioral therapy with a medication regimen versus treatment using only medication. Early results reveal that when medication and cognitive behavioral approaches are combined, social skills and problem-solving are positively affected and improvements are made. Using cognitive behavioral approaches, in addition to medication, will hopefully lead to positive long-term benefits and reduce possible recurring depression in adult life.


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7. Dysthymic Disorder (300.4)

    • DSM-IV-TR criteria
      • A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. NOTE: In children and adolescents, mood can be irritable and duration must be at least 1 year. The individual must have been depressed for at least 22 months during the past 2 years. This type of disorder is classified as unipolar, where there is only severe depression.
      • B. Presence, while depressed, of two (or more) of the following:
        1. poor appetite or overeating
        2. insomnia or hypersomnia
        3. low energy or fatigue
        4. low self-esteem
        5. poor concentration or difficulty making decisions
        6. feelings of hopelessness
      • C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
      • D. No Major Depressive Episode has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission.
        • NOTE: There may have been a previous Major Depressive Episode provided there was a full remission (no significant signs or symptoms for 2 months) before development of the Dysthymic Disorder, there may be superimposed episodes of Major Depressive Disorder, in which case both diagnoses may be given when the criteria are met for a Major Depressive Disorder
      • E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder.
      • F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
      • G. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
      • H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • Specify If:
      • Early Onset: if onset is before age 21 years
      • Late Onset: if onset is age 21 years or older
    • Specify (for most recent 2 years of Dysthymic Disorder):
      • With Atypical Features
    • Associated features
      • Many of the associated features of Dysthymic Disorder are similar to features of Major Depressive Disorder. Changes in sleep patterns, appetite, significant weight gain or loss, and psychomotor symptoms are seen less than in those patients with Major Depressive Disorder. Some of the most common symptoms to be associated with Dysthymic Disorder are feelings with inadequacy; social withdrawal; general loss of interest or pleasure; feelings of guilt or brooding about the past; excessive anger; decreased activity; productivity; or effectiveness. Around 75 percent of people who develop Dysthymic Disorder without ever having Major Depressive Disorder will develop Major Depressive Disorder within the next five years. Problems can occur when treatment becomes necessary, as the individual at that time may have become so accustomed to his depressed mood, he may not see anything that needs discussing. Some researchers say that the studies show that the spontaneous remission rate for Dysthymic Disorder could be as low as 10%. Some evidence found over the last ten years suggests that the with active treatment the plausible outcome is significantly increased (meaning there is a higher chance of a spontaneous recovery.) Dysthymic Disorder is often comorbid with Borderline, Histrionic, Narcissistic, Avoidant, and Dependent personality disorders in adults. In children, it can be comorbid with Attention Deficit/Hyperactive Disorder, Conduct Disorder, Anxiety Disorders, Learning Disorders, and Mental Retardation.
    • Child vs. adult presentation
      • In children, Dysthymic Disorder occurs consistently equal in both sexes. Both Children and adolescents, who have Dysthymic Disorder, display moods of irritability, crankiness, and depression. These attributes of Dysthymic Disorder usually impair the individual’s school performance and most social interaction. Children who display Dysthymic Disorder also show to have low self esteem, tend to be pessimistic and, have poor social skills. Most patients with dysthymia recall having feelings of unhappiness during their childhood but do not know why. First onset occurs during adolescence or early adulthood. Some people that develop dysthymia do not get treated if it occurs during adolescence because they do not know happiness, and they believe that is just the way life is. Symptoms in children may present as feelings of irritability rather than being depressed, and these symptoms only need occur for one year.
    • Gender and cultural differences in presentation
      • Women are 2 to 3 times more likely to develop this disorder. However, before puberty and after menopause, men and women are affected about the same. Females outnumber males 2:1 during childbearing years. Little research has been done to show differences between races, however, it is more common among African Americans and Mexican Americans.
    • Epidemiology
      • Dysthymic disorder, lifetime prevalence for many people, affects about 6% of the general population. In a year, about 3% of the general population has this disorder.
    • Etiology
      • The cause of dysthymia is unclear but there are several factors that may cause it. They are
        • Genetic predisposition
          • Dysthymic Disorder is most prevalent among first-degree biological relatives of people with Major Depressive Disorder or Dysthymic Disorder then people out in the general population.
        • Biological factors
        • Chronic stress
        • Chronic medical illness
        • Psychosocial factors, such as isolation, loss
    • Empirically supported treatments
      • There has been little research conducted on Dysthymic Disorder. Medications that are used to treat Dysthymic Disorder have originated from studies that studied Major Depressive Disorder. Dysthymic Disorder is a milder but longer lasting form of Major Depressive Disorder. Researchers have carried over the findings from the studies of Major Depressive Disorder to Dysthymic Disorder. Furthermore this treatment taken from Major Depressive Disorder has been shown to be very effective in treating and managing Dysthymic Disorder. The most effective treatments that have shown success are as follows: antidepressants, MAOI, and SSRI antidepressants. The only other treatments that have been found to be effective in the fight against Dysthymic Disorder are supportive psychotherapy and psychoeducation. This helps the patient and the patient’s family to understand the illness, helps improve the patient’s compliance and allows the family to be more cooperative with their loved one’s recovery. Cognitive therapy is used to change the pessimistic ideas. It also helps a person realize which problems are truly problems and which ones are minor. Problem solving helps individuals identify which areas of life need to be changed so one can better cope with this disorder instead of sustain it.
    • Links
    • Additional Information:
      • Dysthymia is a milder form of major depression. Periods of feeling normal can last up to a couple of months but usually go back to feelings of depression (2009). People who are diagnosed with this disorder before age 21 tend to have a higher rate of developing a personality disorder (2009). Dysthymic symptoms can often go unnoticed so this population becomes untreated as well. Some medical conditions, including neurological disorders (such as multiple sclerosis and stroke), hypothyroidism, fibromyalgia, and chronic fatigue syndrome, are associated with dysthymia. Investigators believe that, in these cases, developing dysthymia is not a psychological reaction to being ill but rather is a biological effect of these disorders (2009). People who have recently encountered a high level of stress such as losing a spouse or divorce can increase the risk for dysthymia (2009).
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8. Depressive Disorder Not Otherwise Specified (311)

    • DSM-IV-TR criteria
    • The Depressive Disorder Not Otherwise Specified category includes disorders with depressive features that do not meet the criteria for Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder With Depressed Mood, or Adjustment Disorder with Mixed Anxiety and Depressed Mood. Sometimes depressive symptoms can present as part of an Anxiety Disorder Not Otherwise Specified. Examples of Depressive Disorder Not Otherwise Specified include:
      1. Premenstrual dysphoric disorder: in most menstrual cycles during the past year, symptoms (e.g., markedly depressed mood, marked anxiety, marked affective liability, decreased interest in activities) regularly occurred during the last week of the luteal phase (and remitted within a few days of the onset of menses). These symptoms must be severe enough to markedly interfere with work, school, or unusual activities and be entirely absent for at least 1 week postmenses.
      2. Minor Depressive Disorder: episodes of at least 2 weeks of depressive symptoms but with fewer than the five items required for Major Depressive Disorder.
      3. Recurrent brief depressive disorder: depressive episodes lasting from 2 days up to 2 weeks, occurring at least once a month for 12 months (not associated with the menstrual cycle)
      4. Postpsychotic depressive disorder of Schizophrenia: a Major Depressive Episode Disorder that occurs during the residual phase of Schizophrenia.
      5. A Major Depressive Episode superimposed on Delusional Disorder, Psychotic Disorder Not Otherwise Specified, or the active phase of Schizophrenia.
      6. Situations in which the clinician has concluded that a depressive disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced.
      7. Seasonal Affective Disorder: seasonal regularity. Symptoms include: intense hunger, weight gain in winter, sleep more than usual, depressed more in the evening than the morning.

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9. Bipolar I Disorder (296.xx)


Manic Depressive (referred to Bipolar Disorder
Manic Depressive (referred to Bipolar Disorder
  • The required criterion for the disorder dictates that the afflicted individual must have at least one manic episode in their life time. Mania is often followed by periods of depression. There is a cyclic nature about the illness. Individuals will fluctuate between episodes of depression and mania; hence the original label “manic depressive”. Although, it should be noted there are periods of normalcy between each episodes, where individuals are able to function. Onset of the disorder often develops in late teens to early twenties. Nearly all individuals with the disorder develop it before age 50
  • Manic episodes can manifest themselves as either irritability or euphoria




    • DSM-IV-TR criteria
    • Diagnostic criteria for 296.0x Bipolar I Disorder, Single Manic Episode
      • A. Presence of only one Manic Episode...and no past major Depressive Episodes.
        • Note: Recurrence is defined as either a change in polarity from depression or an interval of at least 2 months without manic symptoms.
        • B. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
      • Specify if:
        • Mixed: if symptoms meet criteria for a Mixed Episode...
      • Specify (for current or most recent episode).
        • Mild, moderate, severe without psychotic features or severe with psychotic features.
        • With Catatonic Features.
        • With Postpartum Onset.
      • Specify the current clinical status of the bipolar I disorder or features of the most recent episode if the full criteria are not currently met for a manic, mixed, or major depressive episode.
        • In partial or full remission
        • With catatonic features
        • With postpartum onset
    • Diagnostic criteria for 296.40 Bipolar I Disorder, Most Recent Episode Hypomanic
        • A. Currently (or most recently) in a Hypomanic Episode
        • B. There has previously been at least one Manic Episode or Mixed Episode
        • C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
        • D. The mood episodes in Criteria a and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
      • Specify:
        • Longitudinal Course Specifiers (With and Without Interepisode Recovery)...
        • With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)...
        • With Rapid Cycling.
    • Diagnostic criteria for 296.4x Bipolar I Disorder, Most Recent Episode Manic
      • A. Currently (or most recently) in a Manic Episode...
      • B. There has previously been at least one Major Depressive Episode...,Manic Episode...,or Mixed Episode...
      • C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
      • Specify
        • Longitudinal Course Specifiers (With and Without Interepisode Recovery)...
        • With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)...
        • With Rapid Cycling...
    • Diagnostic criteria for 196.6x Bipolar I Disorder, Most Recent Episode Mixed
      • A. Currently (or most recently) in a Mixed Episode...
      • B. There has previously been at least one Major Depressive episode..., Manic Episode...,or Mixed Episode...
      • C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
      • Specify (for current or most recent episode):
        • Severity/Psychotic/Remission Specifiers...
        • With Catatonic Features...
        • With Postpartum Onset...
      • Specify:
        • Longitudinal Course Specifiers (With and Without Interepisode Recovery)...
        • With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)...
        • With Rapid Cycling...
        • Diagnostic criteria for 296.5x Bipolar I Disorder, most Recent Episode Depressed
          • A. Currently (or most recently) in a Major Depressive Episode...
          • B. There has previously been at least one Manic Episode or Mixed Episode
          • C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
    • Specify (for current or most recent episode)
      • Severity/Psychotic/Remission Specifiers...
      • Chronic...
      • With Catatonic Features...
      • With Melancholic Features...
      • With Atypical Features...
      • With Postpartum Onset...
    • Specify:
      • Longitudinal Course Specifiers (With and Without Interepisode Recovery)...
      • With Seasonal Pattern (applies only to the pattern of major Depressive Episodes)...
      • With Rapid Cycling...
    • Associated features
      • Suicide is very prevalent in individuals with bipolar I disorder. It is thought that somewhere between 10 and 15% of bipolar patients will actually complete suicide; many more may attempt it. Those with bipolar I are more at risk to have an alcohol or other substance use/abuse problem, and this can lead to a worse course for their bipolar disorder. They may also show violent behaviors during the course of their disorder.
      • Many problems are associated with bipolar I disorder. Violent behaviors could include child abuse, spouse abuse, or other worse violent actions. Problems with school such as truancy or failure are common, and later in life occupational success is also very difficult to attain or maintain. Episodic antisocial behaviors may also present themselves in bipolar I individuals. Maintaining stable relationships is also a problem for individuals with bipolar I disorder, and divorce is common.
      • A person with Bipolar Disorder will resist treatment.
      • Include mood lability and depressive symptoms that may last moments or minutes or days.
    • Child vs. adult presentation
      • 10% to 15% of adolescents with recurrent Major depressive episodes will develop Bipolar I disorder. Mixed episodes occur most often in adolescents and young adults.
      • Bipolar disorder in children: http://www.youtube.com/watch?v=2OfNPiZz3Lw
external image singh_tab3.jpg
http://www.psychiatrymmc.com/pediatric-bipolar-disorder-diagnostic-challenges-in-identifying






    • Gender and cultural differences in presentation
      • There has not been a reported difference in race or ethnicity and the presence of bipolar I. Some clinicians believe that bipolar I disorder is over-diagnosed in some ethnic groups and in younger individuals.
      • Gender affects the order of which the disorder appears. Males are more likely to have manic episodes first. Women are most likely to have major depressive disorder first.
      • It is equally common in men and women, even though they initially display symptoms differently.
      • Manic episodes in men usually occur much more than major depressive episodes; in women, the major depressive episodes occur more frequently.
      • The different episodes may be intensified in women during the premenstrual period.
      • Rapid cycling is more common in women.
      • The course of BD illness may be worse among African American patients,who are more likely to have attempted suicide and been hospitalized then white patients.
      • African American adolescents with bipolar disorder are treated for longer periods with atypical antipsychotics than Caucasian adolescents, even after adjusting for the severity of psychotic symptoms.
    • Epidemiology
      • Bipolar Disorder 1 is common in the United States with a lifetime prevalence between 0.4 and 1.6%. Initial onset of Bipolar 1 is between age 15 and 24. When properly diagnosed and treated, Bipolar Disorder 1 often has a remission period of 5 years. After 5 years a recurrence is common.
    • Etiology
      • First degree biological relatives have a higher chance of getting this disorder from their relatives that have it. They have a 4% to 24% chance of getting it.
      • Tests were done and twin and adoption studies show strong evidence of a genetic influence.
      • Estimates of the heritability of BD range from 59% to 87%. A review of studies indicated that the concordance rates for monozygotic twins average 57%, whereas the concordance rate for dizygotic twins averages 14%.
      • The risk of BD among children of bipolar parents is four times greater than the risk among children of healthy parents.
    • Empirically supported treatments
      • The usual treatment for Bipolar I Disorder is lifelong therapy with a mood-stabilizer (either lithium, carbamazepine, or divalproex / valproic acid) often in combination with an antipsychotic medication.
      • In mania, an antipsychotic medication and/or a benzodiazepine medication is often added to the mood-stabilizer.
      • In depression, quetiapine, olanzapine, or lamotrigine is often added to the mood-stabilizer.
      • Combination of supportive psychotherapy, psychoeducation, and the use of a mood-stabilizer.
    • Single Manic Episode- for the DSM-V
    • Draft Criteria for Bipolar I Disorder- Retain structure, with changes limited to the definitions of mood episodes that define each.
    • Diagnostic criteria for Bipolar I Disorder, Single Manic Episode
      • A. Presence of only one Manic Episode (see Criteria for Manic Episode) and no past Major Depressive Episodes.Note: Recurrence is defined as either a change in polarity from depression or an interval of at least 2 months without manic symptoms.
      • B. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specifiers and/or current features have not yet been reviewed by the Workgroup for bipolar disorder. It is anticipated that specifiers and/or features that apply across the mood disorders will be consistent across major depression and bipolar disorder. The bipolar specific rapid cycling specifier is under review to consider whether to keep as is, eliminate, or modify.


The following video is an interview with a young woman who has experienced a manic and hypomanic episodes. She discusses her behavior during the [[http: http://www.youtube.com/watch?v=TiGRi0kGg_s|mania and hypomania]]
(Video uploaded by exception721, direct link http://www.youtube.com/watch?v=TiGRi0kGg_s)

Both bipolar and unipolar disorders are said to be heritable. Pathological disturbances of mood may follow a ‘bipolar’ course, where normal moods may fluctuate between mania and depression or in a ‘unipolar’ course will be only depressive moods. These disorders could be heritable based on the factors of neurochemical, neuroendocrine, and automatic abnormalities. The basis for these abnormalities has not been established. Bipolar disorder can skip a generation in most cases.




external image mban1006l.jpg

Additional Information:

The number of children and adolescents of being diagnosed with bipolar disorder is increasing. Along with the over diagnosis, the children and teens are being over treated with medications as well. Atypical antipsychotics have been diagnosed, and some are proven as an effective treatment for bipolar disorder (Singh, Ketter, & Chang, 2010). “The efficacy of an atypical antipsychotic is defined in terms of treatment response rates or remission of illness. Response rates are commonly reported as a change in a symptom score as determined by clinical assessments of mania from baseline to endpoint. The Young Mania Rating Scale (YMRS) is a commonly used validated instrument to determine the degree of manic symptomatology (Singh, et al., 2010).” Olanzapine is used for the treatment of manic or mixed episodes in Bipolar I disorder, usually in adolescents 13 to 17 years old. The findings indicated that weight gain might be a possibility and outweigh the benefits of the drug (Singh, et al., 2010). “In 2007, risperidone became the first atypical antipsychotic to receive FDA approval as monotherapy for short-term treatment of acute manic or mixed BD episodes in youths aged between 10 and 17 years (Singh, et al., 2010).” This drug does indicate weight gain therefore physicians need to monitor the patients every six months.

Lithium was studied to determine the relevancy of the drug in cases of severe manic episodes and other disorders related to the manic episodes such as bipolar. Lithium is a relevant drug in the treatment of moderate to severe manic episode, with an efficacy similar to those of most other compounds (Storosum, Wohlfarth, Schene, Elferink, Van Zwieten, & Brink, 2007). The justification of lithium as a first-line treatment of the algorithm in the treatment of manic episode, however, does not only depend on the magnitude of effect in placebo-controlled studies but also on other short- and long-term efficacy and safety considerations (Storosum, et al., 2007). Nevertheless, the results from our meta-analysis may contribute to the discussion about the place of lithium in the treatment of manic episode (Storosum, et al., 2007).

Bipolar disorder (BP) is a debilitating mental illness that affects a significant number of individuals. In this study, there are differences found between mixed versus manic bipolar disorder (Shah, Averill, & Shack, 2004). The primary diagnostic feature, according to DSM-IV criteria (1), is a distinct period of abnormally and persistently elevated, expansive or irritable mood lasting for at least one week. In addition, at least three of the following symptoms are present: grandiosity, decreased need for sleep, pressured speech, and flight of ideas, distractibility, hyperactivity, or risk taking behavior (Shah, et al., 2004). Subsets of BP patients are diagnosed with mixed episodes (BPX). These individuals meet the criteria for both a manic and a major depressive episode; however, the depressive symptoms need only to be present for one week. Individuals who develop BPX have a more inconsistent pattern in age of onset than those with BPM (manic bipolar). Among individuals with BPM, no gender differences have been reported in number of manic episodes; however, women were more likely to be hospitalized (Shah, et al., 2004). Among males with BP, their first episode is more likely to be manic, whereas women are more likely to experience a depressive episode. Men tend to be more hyperactive, grandiose, and to engage in risky behavior, and women tend to report more racing thoughts and distractibility. Studies report mixed findings regarding co morbid substance abuse, with either women or men being found to have more substance-related co morbidity (Shah, et al., 2004). Those diagnosed with BPX are more likely to be women and they tend to have a greater number of depressive symptoms during manic episodes. The most common co-morbidity is substance abuse, followed by anxiety disorders and eating disorders. Co-morbid substance abuse is more common among adolescents and among individuals diagnosed with BPX (Shah, et al., 2004). Although there are differences shown, these disorders also have similarities.

Several people wonder if there are differences between child and adult onset of bipolar disorder. The pediatric bipolar disorder is different from the adult by classifying nine symptom classes. Firstly there is elated mood, defined by silliness, giddiness and feeling invincible. Children in this state are easily overwhelmed, and their affect may oscillate quickly from excitation to a state of anxious distress (Bradfield, 2010). Secondly, irritable mood (one of the cardinal features of pediatric bipolar disorder) manifests in aggressive, hostile behaviors with intense, inconsolable responses to stressors (Bradfield, 2010). Inflated self-esteem or grandiosity is the next category of reported symptoms. The child may make unsupportable statements such as “I am the cleverest boy in the whole world”, or “The teachers could learn a few lessons from me”. A decreased need for sleep is evident in children with bipolar mood disorder (Bradfield, 2010). They awaken from little sleep, feeling refreshed and energized. Pressure of speech is noted, with children constantly talking, dominating the interpersonal space, and seeking attention by being excessively entertaining. Constant goal-directed activity is observed as a central feature. Children may be overwhelmed by a frenzy of activity, with aims to achieve unrealistic goals. The constant search for pleasurable activities is also observed, a feature that often manifests in children showing little awareness of the social surroundings (Bradfield, 2010) . The emergence of depression in children living with bipolar disorder is age-specific in its manifestation. Depressed children may report feeling “crabby”; their parents may describe “excessive whining” in the child; they may cry for no apparent reason, withdraw and isolate themselves, exhibit fluctuations in mood from irritability to tearfulness, and may engage in minor self-injurious behaviors such as skin-pinching (Bradfield, 2010). These children may develop a painful sensitivity to rejection, due to the incongruity of their behaviors compared with their peers. The final category of symptoms in bipolar children relates to the psychotic spectrum. Children presenting what could be called an atypical mania could exhibit auditory and visual hallucinations, usually in relation to mood-congruent delusions of grandiosity (Bradfield, 2010). In terms of thought form, the significance of flight of ideas, spontaneously, and excessive speed and production of thoughts has been noted (Bradfield, 2010).

The following can be considered as red flags pointing to heightened risk: Firstly, people with Bipolar Mood Disorder who have a family history of suicidal behaviour are more likely to attempt suicide than those who do not (Bradfield, 2010). Secondly, a history of physical or sexual abuse is positively correlated with suicide attempts. These two factors must be seen in combination with the specific clinical presentation of the bipolar child (Bradfield, 2010). The majority of people with Bipolar Mood Disorder who attempt suicide frequently present with mixed manic states, multiple depressive episodes, co-morbid anxiety or panic disorders and/or substance abuse or dependence (Bradfield, 2010). Furthermore, children presenting with a history of mixed episodes as well as concurrent psychotic symptoms are more likely to evince suicidal ideation (Bradfield, 2010). The treatment of children with psychiatric medication is a sensitive process that requires nuanced judgements and considers each child in relation to his/her development (Bradfield, 2010).

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10. Bipolar II Disorder (296.89)


    • DSM-IV-TR criteria
      • A. Presence (or history) of one or more Major Depressive Episodes.
      • B. Presence (or history) of at least one Hypomanic Episode.
      • C. There has never been a Manic Episode or a Mixed Episode.
      • D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
      • E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
      • Specify current or most recent episode:
        • Hypomanic: if currently (or most recently) in a Hypomanic Episode
        • Depressed: if currently (or most recently) in a Major Depressive Episode
      • If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or features:
        • Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features
          • NOTE: Fifth-digit codes cannot be used here because the code for Bipolar II Disorder already uses the fifth digit.
        • Chronic
        • With Catatonic Features
        • With Melancholic Features
        • With Atypical Features
        • With Postpartum Onset
      • If the full criteria are not currently met for a Hypomanic or Major Depressive Episode, specify the clinical status of the Bipolar II Disorder and/or features of the most recent Major Depressive Episode (only if it is the most recent type of mood episode):
        • In partial remission, In Full Remission
          • NOTE: Fifth-digit codes cannot be used here because the code for Bipolar II Disorder already uses the fifth digit.
        • Chronic
        • With Catatonic Features
        • With Melancholic Features
        • With Atypical Features
        • With Postpartum Onset
        • Specify:
          • Longitudinal Course Specifiers (With and Without Interepisode Recovery)
          • With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)
          • With Rapid Cycling
    • Associated features
      • Suicide is also a risk for individuals with bipolar II disorder. Completion rates are somewhere between 10 and 15 percent, although many more may attempt it. Like bipolar I, issues with school and careers are also present. Truancy or failure in school and occupational failure are common. Divorce is also very common in bipolar individuals. Bipolar II is often comorbid with Substance Abuse or Dependence, Anorexia Nervosa, Bulimia Nervosa, Attention Deficit/Hyperactivity Disorder, Panic Disorder, Social Phobia, and Borderline Personality Disorder.
      • Individuals with bipolar 2 disorders tend to have some creativity. A large number of people with bipolar 2 are well involved in art. Also individuals with bipolar 2 disorders are characterized as outgoing and more daring that people without bipolar 2 disorders.
    • Child vs. adult presentation
      • Bipolar 2 disorder is often more severe, more chronic, and more rapid cyclers in children versus adults. Bipolar 2 is very uncommon late in life. However, neurologic impairment can be associated with some older adults. Furthermore, adolescents are confined more to substance abuse with bipolar 2 than with their counterparts.
    • Gender and cultural differences in presentation
      • In general, bipolar disorders are equally in both men and women. However, women may actually be more at risk than men. Women are known to have more rapid episodes than males. The average age for bipolar 2 disorder is age 22 and it is uncommon after the age of 40. Also with bipolar disorders, in general, women tend to report experiences of depression first whereas men report experiencing mania.
      • Men have predominately Hypomanic Episodes, and women have mainly Major Depressive Episodes.
      • Women with Bipolar II Disorder may have an increased risk of developing episodes in the postpartum period.
    • Epidemiology
      • The average lifetime prevalence rate for Bipolar II Disorder is approximately 0.5 percent.
      • The average age for children with bipolar 2 disorder is 10 which is found in 0.3%-0.5% of patients. Bipolar 2 disorder is less common in older adults.
    • Etiology
      • Genetics play a big factor of people with bipolar 2 disorder. Individuals with family members that have bipolar 2 disorders have a big risk of bipolar 2. Antidepressants may be a potential risk for bipolar patients in that it could trigger more rapid cycling and antidepressants can induce hypomania. There are also brain abnormalities in that the neurotransmitters dopamine, serotonin, and nor epinephrine can be associated with mood disturbances.
    • Empirically supported treatments
      • There seem to be different alternatives methods in treating bipolar 2 disorders. However, in treating all bipolar disorders, lithium is the desired treatment. Therapy also tend to play a vital role in the treatment of bipolar disorders in that it helps the client to understand the importance of the illness and helps them to recognize when a hypomanic or a depressive episode is occurring.
    • DSM-V Revisions
    • Specify current or most recent episode:
Specifiers and/or current features have not yet been reviewed by the Workgroup for bipolar disorder. It is anticipated that specifiers and/or features that apply across the mood disorders will be consistent across major depression and bipolar disorder. The bipolar specific rapid cycling specifier is under review to consider whether to keep as is, eliminate, or modify

Additional Information:

Patients with Bipolar Disorder are at a higher risk than any other disorder on the listed on the axis I. 25-56% of patients are at risk of attempting suicide; this is a major problem in bipolar disorder (Valtonen, Suominen, Haukka, Mantere, Leppämäki, Arvilommi, et al, 2008). The suicidal behavior is related to the depressive aspects of the illness. The highest levels of suicide ideation were at the point when individuals had mixed phases of the illness and then peaking off into the more depressive stages (Valtonen, et al., 2008). The suicide thoughts were more likely to occur in Bipolar Disorder II rather than Bipolar Disorder I. The reason for this is because the bipolar II disorder patients spend more time during the mixed phases of depression. However both bipolar I and II are at high risk for suicide (Valtonen, et al., 2008). Individuals with bipolar disorders are prone to substance abuse such as: nicotine dependence, and alcohol abuse. Nicotine is the highest drug used in bipolar disorder followed by alcohol. For illegal substances, marijuana was the highest found to be abused (Leventhal & Zimmerman, 2010).

Cognitive impairment exists in both subtypes of Bipolar I and II disorders. Research has found that performance levels in verbal memory, working memory, psychomotor speed, and executive function were reduced in bipolar I disorder patients, but that performance levels only in working memory and psychomotor speed were reduced in bipolar II disorder patients (Yih-Lynn, H., Yi-Syuan, W., Jo Yung-Wei, W., Min-Hsien, H., Hui-Chun, C., Sheng-Yu, L., et al., 2009). Bipolar I patients impaired across cognitive domains (except for visual memory), while Bipolar II patients were unimpaired on verbal memory measures (Yih-Lynn, et al., 2009). Two possible factors involved in bipolar I patients having more severe neuropsychological deficits than Bipolar II patients might be the presence of psychotic symptoms and the effect of medication. Bipolar I patients generally have a history of frequent psychotic symptoms; however, one recent study reported no correlation between a history of psychotic symptoms and cognitive impairment (Yih-Lynn, et al., 2009). Moreover, the presence of psychotic symptoms is one of the DSM-IV criteria for diagnosing bipolar I. Antipsychotic treatments are used more frequently in patients with Bipolar I (Yih-Lynn, et al., 2009). Some studies have associated cognitive deficits with antipsychotic medication rather than with psychotic symptoms; however, the effect of medication is difficult to control for and to evaluate in a clinical setting (Yih-Lynn, et al., 2009). Other studies have reported cognitive deficits in the first-degree relatives of bipolar disorder patients; thus, people have questioned whether the neuropsychological functional impairments found in the patients were due to the antipsychotics or to other medication (Yih-Lynn, et al., 2009). Further studies are needed to provide additional evidence (Yih-Lynn, et al., 2009).

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11. Cyclothymic Disorder (301.13)

    • DSM-IV-TR criteria
      • A. For at least 2 years, the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode. Note; in children and adolescents, the duration must be at least 1 year..
      • B.. During the above 2 year period (1 year in children and adolescents), the person has not been without the symptoms in Criteria A for more than 2 months at a time
      • C. No Major Depressive Episode, Manic Episode, or Mixed Episode has been present during the first 2 years of the disturbance.
        • Note; After the initial 2 years ( 1 year in children and adolescents) of Cyclothymic Disorder, there may be superimposed Manic or Mixed Episodes in which case both Bipolar 1 Disorder and Cyclothymic Disorder may be diagnosed) or major Depressive Episode (in which case both Bipolar 2 Disorder and Cyclothymic Disorder, Delusional Disorder may be diagnosed).
      • D. The symptoms in Criteria A are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
      • E. The symptoms are not due to the direct physiological effects of a substance (e.g. a drug abuse, a medication) or a general medical conditioned (e.g. hyperthyroidism).
      • F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • Associated features
      • This is a chronic but a less severe case of Bipolar disorder. The individual experiences numerous hypomanic episodes and many periods of depression over a two year period. Some periods of moods may last as long as two months in some individuals. There will also be "normal" periods of time lasting up to two months. In the first two years, there cannot be any evidence of a Manic Episode or any history of major depressive episodes
      • Cyclothymic Disorder is a chronic, fluctuating mood disturbance with numerous periods of hypomanic symptoms and depressive symptoms. These symptoms do not qualify for either a diagnosis of a full Manic Episode or Major Depressive Episode.
      • Substance Related Disorders and Sleep Disorders can be comorbid with Cyclothymic Disorder.
      • There is a 15 to 50 percent risk that an individual with Cyclothymic Disorder will later develop one of the Bipolar II disorders.
    • Child vs. adult presentation
      • Presence of Cyclothymic Disorder early in life may increase the likelihood of developing other Mood Disorders later in life (especially the Bipolar Disorders.)
      • In children and/or adolescents, symptoms only need to be present for one year as opposed to two years in adults.
    • Gender and cultural differences in presentation
      • Cyclothymic Disorder seems to be equally common in both men and women. However in clinical settings women are more likely to present for treatment.
    • Epidemiology
      • General lifetime prevalence rates are from 0.4% to 1%. Prevalence rates for mood disorder clinics can range between 3% to 5%.
    • Etiology
      • Major Depressive Disorder and Bipolar I or II seem to be more common in the First-degree biological relatives of people with Cyclothymic Disorder then in the normal population. Also, Cyclothymic Disorder may be more common in first-degree biological relatives of those with Bipolar I.
    • Empirically supported treatments
      • There are various treatment options available for those patients with Cyclothymia Disorder. A simple change in lifestyle could be a key component. An example would be getting plenty of exercise. Exercise has been known to regulate mood and also help with emotional stability. This will not cure Cyclothymia of course, but it may offer the patient some relief.
      • Medication is another options. Some possible medicaations that could be prescribed are lithium, anti-seizure medication, antipsychotics, and antianxiety medication. Some alternate medications are magnesium, hypericum perforatum, SAMe, and Omega-3 fatty acids.
      • There are also therapy options if the patient does not want a medication. These are also a little safer than medication. Some examples are cognitive behavioral therapy, interpersonal therapy, and group therapy.
    • DSM-V
      • Note: There will be no changed in this disorder in the DSM-V

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12. Bipolar Disorder Not Otherwise Specified (296.80)

    • DSM-IV-TR criteria
      • A. Very rapid alteration (over days) between manic symptoms and depressive symptoms that meet symptom threshold criteria but not minimal duration criteria for Manic, Hypomanic, or Major Depressive Episodes.
      • B. Recurrent Hypomanic Episodes without intercurrent depressive symptoms
      • C. A Manic or Mixed Episode superimposed on Delusional Disorder, residual Schizophrenia, or Psychotic Disorder Not Otherwise Specified.
      • D.Hypomanic Episodes, along with chronic depressive symptoms, that are too infrequent to qualify for a diagnosis of Cyclothymic Disorder.
      • E. Situations in which the clinician has concluded that a Bipolar Disorder is present but in unable to determine whether it is primary, due to general medical condition, or substance induced
    • Bipolar I Disorder - Most Recent Episode Unspecified
    • Draft Criteria for Bipolar I Disorder- Retain structure, with changes limited to the definitions of mood episodes that define each
      • Criteria, except for duration, are currently (or most recently) met for a Manic (see
      • Criteria for Manic EpisodeThere has previously been at least one Manic Episode (see Criteria for Manic Episode).
        1. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
        2. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
        3. The mood symptoms in Criteria A and B are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).


13. Mood Disorder Due to a General Medical Condition (293.83)

    • DSM-IV-TR criteria -- Mood Disorder Due to ...[Indicate the General Medical Condition]
      • A. prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either ( or both) of the following:
        1. depressed mood or markedly diminished interest or pleasure in all, or almost all, activities
        2. elevated, expansive, or irritable mood
      • B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
      • C. The disturbance is not better accounted for by another mental disorder (e.g., Adjustment Disorder with Depressed Mood in response to the stress of having a general medical condition)
      • D. The disturbance does not occur exclusively during the course of a delirium.
      • E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • Specify type:
      • With Depressed Features: if the predominant mood is depressed but the full criteria are not met for a Major Depressive Episode
      • With Major Depressive-Like Episodes: if the full criteria are met (except Criterion D) for a Major Depressive Episode
      • With Manic Features: if the predominant mood is elevated, euphoric, or irritable
      • With Mixed Features: if the symptoms of both mania and depression are present but neither predominates
      • Coding Note: Include the name of the general medical condition on Axis I; also code the general medical condition on Axis III
      • Coding Note: If depressive symptoms occur as part of a preexisting Vascular Dementia, indicate the depressive symptoms by coding the appropriate subtype.
    • Associated features
      • An individual may have different conditions. A person may have degenerative neurological conditions such as Parkinson's or Huntington's disease, or they may have cerebrovascular, metabolic conditions, autoimmune conditions, endocrine conditions, cancer, viral or other infections.
    • Differential Diagnosis:
      • A separate diagnosis of Mood Disorder Due to a General Medical Condition is not given if the mood disturbance occurs exclusively during the course of a delirium. In contrast, a diagnosis of Mood Disorder Due to a General Medical Condition may be given in addition to a diagnosis of dementia if the mood symptoms are a direct etiological consequence of the pathological process causing the dementia and if the mood symptoms are a prominent part of the clinical presentation (e.g., Mood Disorder Due to Alzheimer's Disease). An exception to this occurs when depressive symptoms occur exclusively during the course of Vascular Dementia.
      • If there is evidence of recent or prolonged substance use (including medications with psychoactive effects), withdrawal from a substance, or exposure to a toxin, a Substance-Induced Mood Disorder should be considered.
      • Mood Disorder Due to a General Medical Condition must be distinguished from Major Depressive Disorder, the Bipolar disorders, and Adjustment Disorder with Depressed Mood. In these Disorders, no specific and direct causative physiological mechanisms associated with a general medical condition can be demonstrated.
    • Child vs. adult presentation
    • Gender and cultural differences in presentation
    • Epidemiology
      • Prevalence estimates for Mood Disorder Due to a General Medical Condition are confined to those presentations with depressive features. Between 25% and 40% of individuals with certain neurological conditions (including Parkinson's disease, Huntington's disease, multiple sclerosis, stroke, and Alzheimer's disease) will develop a marked depressive disturbance at some point during the course of the illness. For general medical conditions without direct central nervous system involvement, rates are far more variable, ranging from more than 60% in Cushing's syndrome to less than 8% in end-stage renal disease.
    • Etiology
    • Empirically supported treatments

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14. Substance-Induced Mood Disorder

    • DSM-IV-TR criteria
      • A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following:
        1. depressed mood or markedly diminished interest or pleasure in all, or almost all, activities
        2. elevated, expansive, or irritable mood
      • B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2):
        1. the symptoms in Criterion A developed during, or within a month of, Substance Intoxication or Withdrawal
        2. medication use is etiologically related to the disturbance
      • C. The disturbance is not better accounted for by a Mood Disorder that is not substance induced. Evidence that the symptoms are better accounted for by a Mood Disorder that is not substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication or are substantially in excess of what would be expected given the evidence that suggests the existence of an independent non-substance-induced Mood Disorder (e.g., a history of recurrent Major Depressive Episodes).
      • D. The disturbance does not occur exclusively during the course of a delirium.
      • E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
        • NOTE: This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the mood symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant indecent clinical attention.
      • Code [Specific Substance]-Induced Mood Disorder:
      • (291.89 Alcohol; 292.84 Amphetamine [or Amphetamine-Like Substance]; 292.84 Cocaine; 292.84 Cocaine; 292.84 Hallucinogen; 292.84 Inhalant; 292.84 Opioid; 292.84 Phencyclidine [or Phencyclidine-Like Substance]; 292.84 Sedative; Hypnotic, or Anxiolytic; 292.84 Other [or Unknown] Substance).
    • Specify type:
      • With Depressive Features: if the predominant mood is depressed
      • With Manic Features: if the predominant mood is elevated, euphoric, or irritable
      • With Mixed Features: if symptoms of both mania and depression are present and neither predominate
      • With Onset During Intoxication: if the criteria are met for Intoxication with the substance and the symptoms develop during the intoxication syndrom
      • With Onset During Withdrawal: if criteria are met for Withdrawal from the substance and the symptoms develop during, or shortly after, a withdrawal syndrome
    • Associated features
      • Individuals may suffer from both independent and substance-induced mental disorders, but substance-induced mental disorders are different because most all of the psychiatric symptoms are caused by substance use, abuse, or withdrawl. Substance-induced mental disorder symptoms can range from anxiety and depression to full psychotic episodes. Physical symptoms usually subside days after substance use has stopped, but some psychotic symptoms can have long-term effects due to toxins damaging the brain (Substance-Induced Disorders, 2009).
    • Differential Diagnosis:
      • Mood symptoms occur commonly in Substance Intoxication and Substance Withdrawal, and the diagnosis of the substance-specific intoxication or substance-specific withdrawal will usually suffice to categorize the symptom presentation. A diagnosis of Substance-Induced Mood Disorder should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the mood symptoms are judged to be in excess of those usually associated with the intoxication or withdrawal syndrome and when the mood symptoms are sufficiently severe to warrant independent clinical attention. For example, dysphoric mood is a characteristic feature of Cocaine Withdrawal. Cocaine-Induced Mood Disorder should be diagnosed instead of Cocaine Withdrawal only if the mood disturbance is substantially more intense than what is usually encountered with Cocaine Withdrawal and is sufficiently severe to be a separate focus of attention and treatment.
      • If substance-induced mood symptoms occur exclusively during the course of a delirium, the mood symptoms are considered to be an associated feature of the delirium and are not diagnosed separately. In substance-induced presentations that contain a mix of different types of symptoms (e.g., mood, psychotic, and anxiety symptoms).
      • A Substance-Induced Mood Disorder is distinguished from a primary Mood Disorder by the fact that a substance is judged to be etiologically related to the symptoms.
      • Substances such as, stimulants, methamphetamines, and cocaine can produce manic, hypomanic, depressive, and mixed episodes. Substances such as alcohol are consumed by individuals with major depressive disorder as a means of self-medication, but this may worsen the effects of depression in those individuals who abuse large amounts of alcohol. Benzodiazepines are said the have effects on the body similar to that of alcohol when consumed over the long-term (Mood Disorder, 2010).
      • Because individuals with general medical conditions often take medications for those conditions, the clinician must consider the possibility that the mood symptoms are caused by the physiological consequences of the general medical condition rather than the medication, in which case Mood Disorder Due to a General Medical Condition is diagnosed.
    • Child vs. adult presentation
    • Gender and cultural differences in presentation
      • Substance-induced mood disorder is equally prevalent in males and females. There are some cultural preferences on the other side of the globe but research is scarce in this area and uncertain. Different cultures view disorders in drastically different contexts, some religious aspects as well as to do with family and the lineage.
    • Epidemiology
      • Although substance-induced mood disorder is listed in the DSM-IV-TR, the DSM-IV-TR does not include any data regarding prevalence or inceidence of this disorder (Nash, 2008).
    • Etiology
      • Mood Disorders can occur in association with intoxication with the following classes of substances: alcohol; amphetamine and related substances; cocaine; hallucinogens; inhalants; opioids; phencyclidine and related substances; sedatives, hypnotics, and anxiolytics; and other or unknown substances.
      • Mood Disorders can occur in association with withdrawal from the following classes of substances: alcohol; amphetamine and related substances; cocaine; sedatives, hypnotics, and anxiolytics; and other or unknown substances.
    • Empirically supported treatments

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15. Severity/Psychotic/Remission Specifiers for current (or most recent) Major Depressive Episode

    • DSM-IV-TR criteria
      • NOTE: code in fifth digit. Mild, Moderate, Severe Without Psychotic Features, and Severe With Psychotic Features can be applied only if the criteria are currently met for a Major Depressive Episode. In Partial Remission and In Full Remission can be applied to the most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode.
      • .x1 -- Mild: Few, if any, symptoms in excess of those required to make the diagnosis and symptoms result in any minor impairment in occupational functioning or in usual social activities or relationships with others.
      • .x2 -- Moderate: Symptoms or functional impairment between "mild" and "severe."
      • .x3 -- Severe Without Psychotic Features: Several symptoms in excess of those required to make the diagnosis, and symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others.
      • .x4 -- Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:
      • Mood-Congruent Psychotic Features: Delusions or Hallucinations whose content is entirely consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.
      • Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to depressive themes), thought insertion, thought broadcasting, and delusions of control.
      • .x5 -- In Partial Remission: Symptoms of a Major Depressive Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Major Depressive Episode lasting less than 2 months following the end of the Major Depressive Episode. (If the Major Depressive Episode was superimposed on Dysthymic Disorder, the diagnosis of Dysthymic Disorder alone is given once the full criteria for a Major Depressive Episode are no longer met.)
      • .x6 -- In Full Remission: During the past 2 months, no significant signs or symptoms of the disturbance were present
      • .x0 -- Unspecified.
    • Associated features
    • Child vs. adult presentation
    • Gender and cultural differences in presentation
    • Epidemiology
    • Etiology
    • Empirically supported treatments

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16. Severity/Psychotic/Remission Specifiers for Manic Episode

    • DSM-IV-TR criteria
      • NOTE: code in fifth digit. Mild, Moderate, Severe without Psychotic Features, and Severe with Psychotic Features can be applied only if the criteria are currently met for a Major Depressive Episode. In Partial Remission and In Full Remission can be applied to the most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode.
      • .x1 -- Mild: Minimum symptom criteria are met for a Manic Episode
      • .x2 -- Moderate: Extreme increase in activity or impairment in judgment
      • .x3 -- Severe Without Psychotic Features: Almost continual supervision required to prevent physical harm to self or others
      • .x4 -- Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:
        • Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person.
        • Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled.
      • .x5 -- In Partial Remission: Symptoms of a Manic Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Manic Episode lasting less than 2 months following the end of the Manic Episode.
      • .x6 -- In Full Remission: During the past 2 months no significant signs or symptoms of the disturbance were present.
      • .x0 -- Unspecified.
    • Associated features
    • Child vs. adult presentation
    • Gender and cultural differences in presentation
    • Epidemiology
    • Etiology
    • Empirically supported treatments

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17. Severity/Psychotic/Remission Specifiers for Mixed Episode

    • DSM-IV-TR criteria
      • NOTE: code in fifth digit. Mild, Moderate, Severe Without Psychotic Features, and Severe With Psychotic Features can be applied only if the criteria are currently met for a Major Depressive Episode. In Partial Remission and In Full Remission can be applied to the most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I Disorder only if it is the most recent type of mood episode.
      • .x1 -- Mild: No more than minimum symptom criteria are met for both a Manic Episode and a Major Depressive Episode. Mild episodes are characterized by the presence of only three or four manic symptoms and five or six depressive symptoms.
      • .x2 -- Moderate: Symptoms or functional impairment between "mild" and "severe." Moderate episodes are characterized by an extreme increase in activity or impairment in judgment.
      • .x3 -- Severe Without Psychotic Features: Almost continual supervision required to prevent physical harm to self or others. Episodes that are Severe Without Psychotic Features are characterized by the need for almost continual supervision to protect the individual from harm to self or others."
      • .x4 -- Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:
        • Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical manic or depressive themes.
        • Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical manic or depressive themes. Included are such symptoms as persecutory delusions (not directly related to grandiose or depressive themes), thought insertion, and delusions of being controlled.
      • .x5 -- In Partial Remission: Symptoms of a Mixed Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Mixed Episode lasting less than 2 months following the end of the Mixed Episode.
      • .x6 -- In Full Remission: During the past 2 months, no significant signs or symptoms of the disturbance were present
      • .x0 -- Unspecified.*
    • Associated features
    • Child vs. adult presentation
    • Gender and cultural differences in presentation
    • Epidemiology
    • Etiology
    • Empirically supported treatments


18. Episode Specifiers that apply to Mood Disorders:


Severity
Psychotic
Remission
Chronic
With Catatonic Features
With Melancholic Features
With Atypical Features
With Post- Partum Onset

MDD, Single Episode
X
X
X
X
X
X
MDD, Recurrent
X
X
X
X
X
X
Dysthymic Disorder




X

Bipolar I,
Single Manic Episode
X

X


X
Bipolar I, Manic
X

X


X
Bipolar I,
Hypomanic Episode






Bipolar I,
Mixed Episode
X

X


X
Bipolar I,
Depressed Episode
X
X
X
X
X
X
Bipolar I,
Unspecified






Bipolar II,
Hypomanic






Bipolar II,
Depressed
X
X
X
X
X
X
Cyclothymic Disorder









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19. Disorders to be listed in the DSM-V

    • Mixed Anxiety Depression
      • Proposed Diagnosed Criteria- The patient has three or four of the symptoms of major depression (which must include depressed mood and/or anhedonia), and they are accompanied by anxious distress. The symptoms must have lasted at least 2 weeks, and no other DSM diagnosis of anxiety or depression must be present, and they are both occuring at the same time.
      • Anxious distress is defined as having two or more of the following symptoms:irrational worry, preoccupation with unpleasant worries, having trouble relaxing, motor tension, fear that something awful may happen.
      • Mixed Features Specifier
      • Draft Criteria for mixed features specifier- this applies to manic, Hypomanic, and depressive episodes.
      • The “with mixed features” specifier applies in episodes where subthreshold symptoms from the opposing pole are present during a full mood episode. While these concurrent “mixed” symptoms are relatively simultaneous, they may also occur closely juxtaposed in time as a waxing and waning of individual symptoms of the opposite pole (i.e., depressive symptoms during hypo/manic episodes and vice versa)
        • A. If predominantly Manic or Hypomanic, full criteria are met for a Manic Episode (see Criteria for Manic Episode) or Hypomanic Episode (see
          • Prominent dysphoria or depressed mood as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
          • diminished interest or pleasure in all, or almost all, activities, (as indicated by either subjective account or observation made by others).
          • psychomotor retardation nearly every day (observable by others, not merely subjective feelings of being slowed down).
          • fatigue or loss of energy.
          • Feelings of worthlessness or excessive or inappropriate guilt (not merely self-reproach or guilt about being sick).
          • recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
        • B. If predominantly Depressed, full criteria are met for a Major Depressive Episode (see Criteria for
          • Elevated, expansive mood
          • Inflated self-esteem or grandiosity
          • More talkative than usual or pressure to keep talking
          • Flight of ideas or subjective experience that thoughts are racing
          • Increase in energy or goal directed activity (either socially, at work or school, or sexually)
          • Increased or excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
          • Decreased need for sleep (feeling rested despite sleeping less than usual (to be contrasted from insomnia).
        • C. Mixed symptoms are observable by others and .represent a change from the person’s usual behavior.
        • D. For those who meet full episode criteria for both Mania and Depression simultaneously, they should be labeled as having a Manic Episode, with mixed features, due to the marked impairment and clinical severity of full mania.
        • E. The mixed symptom specifier can apply to depressive episodes experienced in Major Depressive Disorder, Bipolar I and Bipolar II disorders.
        • F. The mixed symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment).
    • Premenstrual Dysphoric Disorder
      • A. In most menstrual cycles during the past year, five(or more) of the following symptoms occurred during the final week before the onset of menses, started to improve within a few days after the onset of menses, and were minimal or absent in the week postmenses, with at least one of the symptoms being either (1), (2), (3), or (4):
        • (1): Depressed mood, feelings of hopelessness, or self-deprecating thoughts
        • (2): Anxiety, tension, feelings of being “keyed up,” or “on edge”
        • (3): Affective lability
        • (4): Irritability, anger or increased interpersonal conflicts
        • (5): Decreased interest in usual activities (e.g., work, school, friends, hobbies)
        • (6): Subjective sense of difficulty in concentration
        • (7): Lethargy, easy fatigability, or marked lack of energy
        • (8): Change in appetite, overeating, or specific food cravings
        • (9): Hypersomnia or insomnia
        • (10): Subjective sense of being overwhelmed or out of control
        • (11): Other physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” and weight gain
      •  B. The symptoms are associated with clinically significant distress or interference with work, school, usual social activities or relationships with others (e.g. avoidance of social activities, decreased productivity and efficiency at work, school or home).
      • C. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as Major Depressive Disorder, Panic Disorder, Dysthymic Disorder, or a Personality Disorder (although it may be superimposed on any of these disorders).
      • D. Criteria A, B, and C should be confirmed by prospective daily ratings during at least two symptomatic cycles. (The diagnosis may be made provisionally prior to this confirmation.)
      • E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment) or a general medical condition (e.g., hyperthyroidism).
      • F. In oral contraceptives users, a diagnosis of Premenstrual Dysphoric Disorder should not be made unless the premenstrual symptoms are reported to be present, and as severe, when the woman is not taking the oral contraceptive.
  • NOTE: The DSM-V includes the severity and rationales for the revisions of the disorders.

  • Link to the DSM-V Revisions of Mood Disorders:**
  • Almlöv, J., Carlbring, P., Berger, T., Cuijpers, P., & Andersson, G. (2009). Therapist factors in Internet-delivered cognitive behavioural therapy for major depressive disorder. Cognitive Behaviour Therapy, 38(4), 247-254. doi:10.1080/16506070903116935.
  • American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC
  • American Psychiatric Association. (2010). DSM-V Development. http://www.dsm5.org/ProposedRevisions/Pages/MoodDisorders.aspx.
  • Basco, M., Ladd, G., Myers, D., & Tyler, D. (2007). Combining medication treatment and cognitive-behavior therapy for bipolar disorder. Journal of Cognitive Psychotherapy, 21(1), 7-15. doi:10.1891/088983907780493304.
  • Bradfield, B. (2010). Bipolar Mood Disorder in children and adolescents: in search of theoretic, therapeutic and diagnostic clarity. South African Journal of Psychology, 40(3), 241-249. Retrieved from Academic Search Complete database.
  • de Graaf, L., Hollon, S., & Huibers, M. (2010). Predicting outcome in computerized cognitive behavioral therapy for depression in primary care: A randomized trial. Journal of Consulting and Clinical Psychology, 78(2), 184-189. doi:10.1037/a0018324.
  • Feeny, N., Danielson, C., Schwartz, L., Youngstrom, E., & Findling, R. (2006). Cognitive-behavioral therapy for bipolar disorders in adolescents: A pilot study. Bipolar Disorders, 8(5 pt 1), 508-515. doi:10.1111/j.1399-5618.2006.00358.x.
  • Iacoviello, B., Alloy, L., Abramson, L., & Choi, J. (2010). The early course of depression: A Longitudinal Investigation of Prodromal Symptoms and Their Relation to the Symptomatic Course of Depressive Episodes. Journal of Abnormal Psychology, 119(3), 459-467. doi: 10.1037/a0020114.
  • Illumistream. (2007, August 23). People sometimes have a hard time understanding the difference between depression and normal sadness. Dr. Eredlyi discusses the different kinds of depression, and how to recognize them.Watch More Health Videos at Health Guru: http://www.healthguru.com/?YT [web log comment]. Retrieved from http://www.youtube.com/watch?v=IeZCmqePLzM&feature=channel
  • Illumistream. (2008, April 6). Depression can be debilitating, but with treatment, people suffering from the condition can notice marked reduction in symptoms [web log comment]. Retrieved from http://www.youtube.com/watch?v=qVEueGutbSs
  • Illumistream. (2007, August 23). Bipolar disorder, which was once called manic depression, is often misunderstood and frequently misrepresented in the popular media. In this video, Dr. Erdelyi explains what Bipolar disorder really is. Retrieved from http://www.youtube.com/watch?v=MBUOoQk0hhU&feature=channel
  • Jungbluth, N., & Shirk, S. (2009). Therapist strategies for building involvement in cognitive-behavioral therapy for adolescent depression. Journal of Consulting and Clinical Psychology, 77(6), 1179-1184. doi: 10.1037/a0017325.
  • Kennard, B., Clarke, G., Weersing, V., Asarnow, J., Shamseddeen, W., Porta, G., et al. (2009). Effective components of TORDIA cognitive–behavioral therapy for adolescent depression: Preliminary findings. Journal of Consulting and Clinical Psychology, 77(6), 1033-1041. doi:10.1037/a0017411.
  • Leventhal, A., & Zimmerman, M. (2010). The relative roles of bipolar disorder and psychomotor agitation in substance dependence. Psychology of Addictive Behaviors, 24(2), 360-365. doi:10.1037/a0019217.
  • Matsunaga, M., Okamoto, Y., Suzuki, S., Kinoshita, A., Yoshimura, S., Yoshino, A., et al. (2010). Psychosocial functioning in patients with treatment-resistant depression after group cognitive behavioral therapy. BMC Psychiatry, 10doi:10.1186/1471-244X-10-22.
  • Mood Disorder (2010). Retrieved from http://en.wikipedia.org/wiki/Mood_disorder#Substance_induced_mood_disorders
  • NAMIvideo. (2008, March 13). Listen to NAMI's Medical Director, Dr. Ken Duckworth, describe mood disorders in children and adolescents [web log comment]. Retrieved from http://www.youtube.com/watch?v=y6iHEQPett8
  • Nash, M. C. (2008). Substance-Induced Mood Disorders, Depression and Mania. Retrieved from http://emedicine.medscape.com/article/286885-overview
  • NIMHgov. (2010, April 9). Bipolar Spectrum Disorder is rare among children. But for parents who may have concerns about their youngsters behavior, Dr. Ellen Leibenluft talks about possible warning signs. Dr. Leibenluft is Senior Investigator and Chief of the Bipolar Spectrum Disorder Section at the National Institute of Mental Health [web log comment]. Retrieved from http://www.youtube.com/watch?v=2OfNPiZz3Lw
  • NIMHgov. (2009, July 29). Video from the National Institute of Mental Health (NIMH) about the causes, symptoms, and treatments of depression [web log comment]. Retrieved from http://www.youtube.com/watch?v=mlNCavst2EU&feature=channel
  • Shah, N., Averill, P., & Shack, A. (2004). Mixed Versus Manic Bipolar Disorder: A Comparison of Demographic, Symptomatic, and Treatment Differences. Psychiatric Quarterly, 75(2), 183-196. Retrieved from Academic Search Complete database.
  • Singh, M., Ketter, T., & Chang, K. (2010). Atypical Antipsychotics for Acute Manic and Mixed Episodes in Children and Adolescents with Bipolar Disorder: Efficacy and Tolerability. Drugs, 70(4), 433-442. Retrieved from Academic Search Complete database.
  • Storosum, J., Wohlfarth, T., Schene, A., Elferink, A., Van Zwieten, B., & Brink, W. (2007). Magnitude of Effect of Lithium in Short-Term Efficacy Studies of Moderate to Severe Manic Episode. Bipolar Disorders, 9(8), 793-798. doi:10.1111/j.1399- 5618.2007.00445.x.
  • Stuhlmiller, C., & Tolchard, B. (2009). Computer-assisted CBT for depression and anxiety: Increasing accessibility to evidence-based mental health treatment. Journal of Psychosocial Nursing and Mental Health Services, 47(7), 32-39. doi:10.3928/02793695-20090527-01.
  • Substance-Induced Disorders. (2009). Substance-Induced Disorders. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK26155/
  • Swann, A., Gerard Moeller, F., Steinberg, J., Schneider, L., Barratt, E., & Dougherty, D. (2007). Manic symptoms and impulsivity during bipolar depressive episodes. Bipolar Disorders, 9(3), 206-212. doi:10.1111/j.1399-5618.2007.00357.x.
  • Valtonen, H., Suominen, K., Haukka, J., Mantere, O., Leppämäki, S., Arvilommi, P., et al.
  • Veronica4kids. (2009, June 18). http://www.AheadWithAutism.com Rescuing Childhood Understanding Bipolar Disorder in Children and Adolescents [web log comment]. Retrieved from http://www.youtube.com/watch?v=-UZHTR5mzq0
  • Warman, D. M., & Beck, A. T. (2003) Cognitive Behavioral Therapy. Retrieved from http://www.nami.org/Template.cfm?Section=About_Treatments_and_Supports&template=/ContentManagement/ContentDisplay.cfm&ContentID=7952
  • West, A., Jacobs, R., Westerholm, R., Lee, A., Carbray, J., Heidenreich, J., et al. (2009). Child and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: Pilot study of group treatment format. Journal of the Canadian Academy of Child and Adolescent Psychiatry / Journal de l'Académie canadienne de psychiatrie de l'enfant et de l'adolescent, 18(3), 239-246. Retrieved from PsycINFO database.
  • Yih-Lynn, H., Yi-Syuan, W., Jo Yung-Wei, W., Min-Hsien, H., Hui-Chun, C., Sheng-Yu, L., et al. (2009). Neuropsychological functions in patients with bipolar I and bipolar II disorder. Bipolar Disorders, 11(5), 547-554. doi:10.1111/j.1399-5618.2009.00723.x. (2008). Differences in incidence of suicide attempts during phases of bipolar I and II disorders. Bipolar Disorders, 10(5), 588-596. doi:10.1111/j.1399- 5618.2007.00553.x.
  • (2009). Symptoms and Diagnosis of Mood Disorders. Depression & Anxiety (Medletter), 5-17. Retrieved from Health Source - Consumer Edition database.