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88 Cards in this Set

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How is mood disorder section of DSM arranged?
1. Episodes
2. Disorders
3. Specifiers.
List the mood disorders?
Depressive Disorders ("unipolar depression"): Major Depressive Disorder, Dysthymic Disorder, and Depressive Disorder Not Otherwise Specified

the Bipolar Disorders: Bipolar I Disorder, Bipolar II Disorder, Cyclothymic Disorder, and Bipolar Disorder Not Otherwise Specified

two disorders based on etiology—Mood Disorder Due to a General Medical Condition and Substance-Induced Mood Disorder
Give quick definition of each depressive disorder
Major Depressive Disorder is characterized by one or more Major Depressive Episodes (i.e., at least 2 weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression).

Dysthymic Disorder is characterized by at least 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms that do not meet criteria for a Major Depressive Episode.

Depressive Disorder Not Otherwise Specified is included for coding disorders with depressive features that do not meet criteria for Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder With Depressed Mood, or Adjustment Disorder With Mixed Anxiety and Depressed Mood (or depressive symptoms about which there is inadequate or contradictory information).
Give quick definition of each bipolar disorders
Bipolar I Disorder is characterized by one or more Manic or Mixed Episodes, usually accompanied by Major Depressive Episodes.

Bipolar II Disorder is characterized by one or more Major Depressive Episodes accompanied by at least one Hypomanic Episode.

Cyclothymic Disorder is characterized by at least 2 years of numerous periods of hypomanic symptoms that do not meet criteria for a Manic Episode and numerous periods of depressive symptoms that do not meet criteria for a Major Depressive Episode.

Bipolar Disorder Not Otherwise Specified is included for coding disorders with bipolar features that do not meet criteria for any of the specific Bipolar Disorders defined in this section (or bipolar symptoms about which there is inadequate or contradictory information).
Give defs of other mood disorders
Mood Disorder Due to a General Medical Condition is characterized by a prominent and persistent disturbance in mood that is judged to be a direct physiological consequence of a general medical condition.

Substance-Induced Mood Disorder is characterized by a prominent and persistent disturbance in mood that is judged to be a direct physiological consequence of a drug of abuse, a medication, another somatic treatment for depression, or toxin exposure.

Mood Disorder Not Otherwise Specified is included for coding disorders with mood symptoms that do not meet the criteria for any specific Mood Disorder and in which it is difficult to choose between Depressive Disorder Not Otherwise Specified and Bipolar Disorder Not Otherwise Specified (e.g., acute agitation)
What do the mood specifiers describe?
status of the current (or most recent) mood episode (i.e.,Severity/Psychotic/Remission Specifiers),

features of the current episode (or most recent episode if the episode is currently in partial or full remission) (i.e., Chronic, With Catatonic Features, With Melancholic Features, With Atypical Features, With Postpartum Onset).

course of recurrent mood episodes (i.e., Longitudinal Course Specifiers, With Seasonal Pattern, With Rapid Cycling)
• Specifiers describing the clinical severity of the current (or most recent) mood episode?
Mild, Moderate, Severe Without Psychotic Features, Severe With Psychotic Features, In Partial Remission, In Full Remission
5 MDD Specifiers describing features of the current episode (or most recent episode if currently in partial or full remission)
Chronic (page 417)

With Catatonic Features (page 417)

With Melancholic Features (page 419)

With Atypical Features (page 420)

With Postpartum Onset (page 422)
• Specifiers describing course of recurrent episodes
Longitudinal Course Specifiers (With and Without Full Interepisode Recovery) (424)

With Seasonal Pattern (page 425)

With Rapid Cycling (page 427)
What is MDD Recording procedure?
1. The first three digits are 296.
2. The fourth digit is either 2 (if there is only a single Major Depressive Episode) or 3 (if there are recurrent Major Depressive Episodes).
3. The fifth digit indicates the severity of the current Major Depressive Episode if full criteria are met as follows: 1 for Mild severity, 2 for Moderate severity, 3 for Severe Without Psychotic Features, 4 for Severe With Psychotic Features. If full criteria are not currently met for a Major Depressive Episode, the fifth digit indicates the current clinical status of the Major Depressive Disorder as follows: 5 for In Partial Remission, 6 for In Full Remission. If current severity or clinical status is unspecified, the fifth digit is 0
Bipolar I Disorder recording procedure?
1. The first three digits are also 296.
2. The fourth digit is 0 if there is a single Manic Episode. For recurrent episodes, the fourth digit indicates the nature of the CURRENT EPISODE (or, if the Bipolar I Disorder is currently in partial or full remission, the nature of the most recent episode) as follows: 4 if the current or most recent episode is a Hypomanic Episode or a Manic Episode, 6 if it is a Mixed Episode, 5 if it is a Major Depressive Episode, and 7 if the current or most recent episode is Unspecified.
3. The fifth digit (except for Bipolar I Disorder, Most Recent Episode Hypomanic, and Bipolar I Disorder, Most Recent Episode Unspecified) indicates the SEVERITY of the current episode if full criteria are met for a Manic, Mixed, or Major Depressive Episode as follows: 1 for Mild severity, 2 for Moderate severity, 3 for Severe Without Psychotic Features, 4 for Severe With Psychotic Features. If full criteria are not met for a Manic, Mixed, or Major Depressive Episode, the fifth digit indicates the current clinical status of the Bipolar I Disorder as follows: 5 for In Partial Remission, 6 for In Full Remission. If current severity or clinical status is unspecified, the fifth digit is 0. For Bipolar I Disorder, Most Recent Episode Hypomanic, the fifth digit is always 0. For Bipolar Disorder, Most Recent Episode Unspecified, there is no fifth digit.
Code for Bipolar II disorder?
diagnostic code is 296.89
General Mood Disorder Recording Procedure
1. Name of disorder (e.g., Major Depressive Disorder, Bipolar Disorder)
2. Specifiers coded in the fourth digit (e.g., Recurrent, Most Recent Episode Manic)
3. Specifiers coded in the fifth digit (e.g., Mild, Severe With Psychotic Features, In Partial Remission)
4. As many specifiers (without codes) as apply to the current or most recent episode (e.g., With Melancholic Features, With Postpartum Onset)
5. As many specifiers (without codes) as apply to the course of recurrent episodes (e.g., With Seasonal Pattern, With Rapid Cycling)
What is essential feature of MDEpisode? In children?
he essential feature of a Major Depressive Episode is a period of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities. In children and adolescents, the mood may be irritable rather than sad.
How many others sx besides depressed mood or anhedonia must there be for MDE?
changes in
sleep
feelings of worthlessness or guilt;
decreased energy;
difficulty thinking, concentrating, or making decisions; or
appetite or weight,
psychomotor activity;
recurrent thoughts of death or suicidal ideation, plans, or attempts
When adding sx up for MDE, does it count if patient had major problem in symptom area before start of episode?
To count toward a Major Depressive Episode, a symptom must either be

newly present or must have
clearly worsened compared with the person's preepisode status.
How often must the symptoms occur?
The symptoms must persist for most of the day, nearly every day, for at least 2 consecutive weeks
How is fxn understood in MDE?
The episode must be accompanied by clinically significant distress or impairment in social, occupational, or other important areas of functioning. For some individuals with milder episodes, functioning may appear to be normal but requires markedly increased effort.
Describe the low mood in MDE
he mood in a Major Depressive Episode is often described by the person as depressed, sad, hopeless, discouraged, or "down in the dumps" (Criterion A1). In some cases, sadness may be denied at first, but may subsequently be elicited by interview (e.g., by pointing out that the individual looks as if he or she is about to cry). In some individuals who complain of feeling "blah," having no feelings, or feeling anxious, the presence of a depressed mood can be inferred from the person's facial expression and demeanor. Some individuals emphasize somatic complaints (e.g., bodily aches and pains) rather than reporting feelings of sadness. Many individuals report or exhibit increased irritability (e.g., persistent anger, a tendency to respond to events with angry outbursts or blaming others, or an exaggerated sense of frustration over minor matters). In children and adolescents, an irritable or cranky mood may develop rather than a sad or dejected mood. This presentation should be differentiated from a "spoiled child" pattern of irritability when frustrated.
Describe anhedonia in MDE?
Loss of interest or pleasure is nearly always present, at least to some degree. Individuals may report feeling less interested in hobbies, "not caring anymore," or not feeling any enjoyment in activities that were previously considered pleasurable (Criterion A2). Family members often notice social withdrawal or neglect of pleasurable avocations (e.g., a formerly avid golfer no longer plays, a child who used to enjoy soccer finds excuses not to practice). In some individuals, there is a significant reduction from previous levels of sexual interest or desire.
Describe the appetite change?
Appetite is usually reduced, and many individuals feel that they have to force themselves to eat. Other individuals, particularly those encountered in ambulatory settings, may have increased appetite and may crave specific foods (e.g., sweets or other carbohydrates). When appetite changes are severe (in either direction), there may be a significant loss or gain in weight, or, in children, a failure to make expected weight gains may be noted (Criterion A3)
Describe sleep difficulties in MDE
The most common sleep disturbance associated with a Major Depressive Episode is insomnia (Criterion A4). Individuals typically have middle insomnia (i.e., waking up during the night and having difficulty returning to sleep) or terminal insomnia (i.e., waking too early and being unable to return to sleep).

Initial insomnia (i.e., difficulty falling asleep) may also occur.

Less frequently, individuals present with oversleeping (hypersomnia) in the form of prolonged sleep episodes at night or increased daytime sleep. Sometimes the reason that the individual seeks treatment is for the disturbed sleep
MDE Psychomotor changes?
Psychomotor changes include agitation (e.g., the inability to sit still, pacing, hand-wringing; or pulling or rubbing of the skin, clothing, or other objects) or

retardation (e.g., slowed speech, thinking, and body movements; increased pauses before answering; speech that is decreased in volume, inflection, amount, or variety of content, or muteness) (Criterion A5).

The psychomotor agitation or retardation must be severe enough to be observable by others and not represent merely subjective feelings
Describe energy change?
Decreased energy, tiredness, and fatigue are common (Criterion A6). A person may report sustained fatigue without physical exertion. Even the smallest tasks seem to require substantial effort. The efficiency with which tasks are accomplished may be reduced. For example, an individual may complain that washing and dressing in the morning are exhausting and take twice as long as usual.
Explain Guilt
The sense of worthlessness or guilt associated with a Major Depressive Episode may include unrealistic negative evaluations of one's worth or guilty preoccupations or ruminations over minor past failings (Criterion A7). Such individuals often misinterpret neutral or trivial day-to-day events as evidence of personal defects and have an exaggerated sense of responsibility for untoward events. For example, a realtor may become preoccupied with self-blame for failing to make sales even when the market has collapsed generally and other realtors are equally unable to make sales. The sense of worthlessness or guilt may be of delusional proportions (e.g., an individual who is convinced that he or she is personally responsible for world poverty). BLAMING ONSELF for being sick and for failing to meet occupational or interpersonal responsibilities as a result of the depression is very common and, unless delusional, is not considered sufficient to meet this criterion
Describe concentration change in MDE?
Many individuals report impaired ability to think, concentrate, or make decisions (Criterion A8). They may appear easily distracted or complain of memory difficulties. Those in intellectually demanding academic or occupational pursuits are often unable to function adequately even when they have mild concentration problems (e.g., a computer programmer who can no longer perform complicated but previously manageable tasks). In children, a precipitous drop in grades may reflect poor concentration. In elderly individuals with a Major Depressive Episode, memory difficulties may be the chief complaint and may be mistaken for early signs of a dementia ("pseudodementia"). When the Major Depressive Episode is successfully treated, the memory problems often fully abate. However, in some individuals, particularly elderly persons, a Major Depressive Episode may sometimes be the initial presentation of an irreversible dementia
Describe suicidal ideation?
Frequently there may be thoughts of death, suicidal ideation, or suicide attempts (Criterion A9). These thoughts range from a belief that others would be better off if the person were dead, to transient but recurrent thoughts of committing suicide, to actual specific plans of how to commit suicide. The frequency, intensity, and lethality of these thoughts can be quite variable. Less severely suicidal individuals may report transient (1- to 2-minute), recurrent (once or twice a week) thoughts. More severely suicidal individuals may have acquired materials (e.g., a rope or a gun) to be used in the suicide attempt and may have established a location and time when they will be isolated from others so that they can accomplish the suicide. Although these behaviors are associated statistically with suicide attempts and may be helpful in identifying a high-risk group, many studies have shown that it is not possible to predict accurately whether or when a particular individual with depression will attempt suicide. Motivations for suicide may include a desire to give up in the face of perceived insurmountable obstacles or an intense wish to end an excruciatingly painful emotional state that is perceived by the person to be without end.
What are MDE exclusion criteria?
By definition, a Major Depressive Episode is not due to the direct physiological effects of a drug of abuse (e.g., in the context of Alcohol Intoxication or Cocaine Withdrawal),

to the side effects of medications or treatments (e.g., steroids), or

to toxin exposure.

Similarly, the episode is not due to the direct physiological effects of a general medical condition (e.g., hypothyroidism) (Criterion D).

Moreover, if the symptoms begin within 2 months of the loss of a loved one and do not persist beyond these 2 months, they are generally considered to result from Bereavement (see page 740), UNLESS they are associated with marked functional impairment
or include:
morbid preoccupation with worthlessness,
suicidal ideation,
psychotic symptoms, or
psychomotor retardation (Criterion E)
What are associated features of MDE?
Individuals with a Major Depressive Episode frequently present with tearfulness, irritability, brooding, obsessive rumination, anxiety, phobias, excessive worry over physical health, and complaints of pain (e.g., headaches or joint, abdominal, or other pains).

During a Major Depressive Episode, some individuals have Panic Attacks that occur in a pattern that meets criteria for Panic Disorder. In children, separation anxiety may occur.

Some individuals note difficulty in intimate relationships, less satisfying social interactions, or difficulties in sexual functioning (e.g., anorgasmia in women or erectile dysfunction in men).

There may be marital problems (e.g., divorce), occupational problems (e.g., loss of job), academic problems (e.g., truancy, school failure), Alcohol or Other Substance Abuse, or increased utilization of medical services.

The most serious consequence of a Major Depressive Episode is attempted or completed suicide. Suicide risk is especially high for individuals with psychotic features, a history of previous suicide attempts, a family history of completed suicides, or concurrent substance use.

There may also be an increased rate of premature death from general medical conditions.

Major Depressive Episodes often follow psychosocial stressors (e.g., the death of a loved one, marital separation, divorce). Childbirth may precipitate a Major Depressive Episode, in which case the specifier With Postpartum Onset is noted
Lab findings in MDE?
No laboratory findings that are diagnostic of a Major Depressive Episode have been identified. However, a variety of laboratory findings have been noted to be abnormal more often in groups of individuals with Major Depressive Episodes
What are sleep lab changes in MDE?
leep EEG abnormalities may be evident in 40%-60% of outpatients and in up to 90% of inpatients with a Major Depressive Episode. The most frequently associated polysomnographic findings include

1) sleep continuity disturbances, such as prolonged sleep latency, increased intermittent wakefulness, and early morning awakening;

2) reduced non-rapid eye movement (NREM) stages 3 and 4 sleep (slow-wave sleep), with a shift in slow-wave activity away from the first NREM period;

3) decreased rapid eye movement (REM) latency (i.e., shortened duration of the first NREM period);

4) increased phasic REM activity (i.e., the number of actual eye movements during REM); and

5) increased duration of REM sleep early in the night.

There is evidence that these sleep abnormalities may persist after clinical remission or precede the onset of the initial Major Depressive Episode among those at high risk for a Mood Disorder (e.g., first-degree family members of individuals with Major Depressive Disorder).
Chemical changes in MDE?
dysregulation of a number of neurotransmitter systems, including the serotonin, norepinephrine, dopamine, acetylcholine, and gamma-aminobutyric acid systems. There is also evidence of alterations of several neuropeptides, including corticotropin-releasing hormone. In some depressed individuals, hormonal disturbances have been observed, including elevated glucocorticoid secretion (e.g., elevated urinary free cortisol levels or dexamethasone nonsuppression of plasma cortisol) and blunted growth hormone, thyroid-stimulating hormone, and prolactin responses to various challenge tests.
Fxnal brain imaging changes in MDE?
increased blood flow in
limbic and paralimbic regions and decreased blood flow in the lateral prefrontal cortex
Changes in late life MDE?
Depression beginning in late life is associated with alterations in brain structure, including periventricular vascular changes.
What sx are more common in children versus teens and adults?
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.
Differences between men and women re: MDE?
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 differential 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. Studies indicate that depressive episodes occur TWICE as frequently in women as in men
Describe the course of a MDE?
Symptoms of a Major Depressive Episode usually develop over days to weeks. A prodromal period that may include anxiety symptoms and mild depressive symptoms may last for weeks to months before the onset of a full Major Depressive Episode.

The duration of a Major Depressive Episode is also variable. An untreated episode typically lasts 4 months or longer, regardless of age at onset.

In a majority of cases, there is complete remission of symptoms, and functioning returns to the premorbid level.

In a significant proportion of cases (perhaps 20%-30%), some depressive symptoms insufficient to meet full criteria for a Major Depressive Episode may persist for months to years and may be associated with some disability or distress (in which case the specifier In Partial Remission may be noted; page 412).

Partial remission following a Major Depressive Episode appears to be predictive of a similar pattern after subsequent episodes. In some individuals (5%-10%), the full criteria for a Major Depressive Episode continue to be met for 2 or more years (in which case the specifier Chronic may be noted; see page 417).
List DDX for MDE
Mood Disorder due to a GMC
Substance Induced Mood Disorder
Manic Episode with irritable mood
mixed episode
ADHD
Elderly Dementia
Sadness not meeting criteria for number of sx, duration, or fxnal severity = Depressive Ds NOS
Criteria for MDE
. 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 INDECIVENESS, 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 suicide

B. The symptoms do not meet criteria for a Mixed Episode (see page 365).
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.e., 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.
What is difference between chilhood and adult dysthymic disorder?
Only needs to be 1 year and
Mood can be irritable rather than depressed
During period of depressed mood, how many criteria are required?
at least two:
Appetite Change
Sleep change
Energy change
Concentration/Decision making change

Hopelessness
Low self-esteem
What is longest sx free period allowed in Dysthymia? Other exclusion criteria?
2 months;
during the first 2 year period, there was NO major depressive episode (if there was a MDE, then MDD, Chronic is dx if still meet MDE presently while MDD in Partial Remission if not meet full criteria)
Never ever having hypo/manic sx
What is Dysthymia X 2 years without MDE in those years but in say 4th year presenting with MDE called?
Double Depression, put both on diagnosis
MDD + Dysthymia; once recover, only Dysthymia listed
Dysthymia specifiers?
Early onset ( less than age 21, versus 21 or older = late onset)
With Atypical Features
Atypical Features =
A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events)

B. Two (or more) of the following features:
(1) significant weight gain or increase in appetite
(2) hypersomnia
(3) leaden paralysis (i.e., heavy, leaden feelings in arms or legs)
(4) long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment
Other common Sx?
feelings of inadequacy;
generalized loss of interest or pleasure; social withdrawal;
feelings of guilt or brooding about the past;
subjective feelings of irritability or excessive anger; and
decreased activity, effectiveness, or productivity
What sx are less common in Dysthymia than in MDD?
vegetative symptoms
(e.g., sleep, appetite, weight change, and psychomotor symptoms)
appear to be less common in dysthymia
n clinical settings up to XX% of individuals with Dysthymic Disorder will develop Major Depressive Disorder within X years
75%, within 5 years
up to 50% with Dysthymia have which polysomnographic findings?
reduced rapid eye movement [REM] latency,
increased REM density,
reduced slow-wave sleep,
impaired sleep continuity
Dysthymic Disorder gender ratio? Lifetime prev?
Point prevalence?
equal in males and females
6%
3%
DSM Criteria for Dysthymia
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.

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 (see page 356) 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.
Give 6 examples of Depressive Ds NOS
1. Premenstrual dysphoric disorder: in most menstrual cycles during the past year, symptoms (e.g., markedly depressed mood, marked anxiety, marked affective lability, 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 usual activities and be entirely absent for at least 1 week postmenses (see page 771 for suggested research criteria).

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 (see page 775 for suggested research criteria).

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) (see page 778 for suggested research criteria).

4. Postpsychotic depressive disorder of Schizophrenia: a Major Depressive Episode that occurs during the residual phase of Schizophrenia (see page 767 for suggested research criteria).

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.
How many different criteria sets are there for BPI and what are they?
Single Manic Episode,
Most Recent Episode Manic,
Most Recent Episode Hypomanic,
Most Recent Episode Mixed,
Most Recent Episode Depressed, and
Most Recent Episode Unspecified
What is first episode mania called?
Bipolar I Disorder, Single Manic Episode, is used to describe individuals who are having a first episode of mania
Bipolar Ds; Full Criteria met for Manic, Depressive, or mixed episode;
What are the specifiers?
Mild, Moderate, Severe Without Psychotic Features, Severe With Psychotic Features (see page 411)

With Catatonic Features (see page 417)

With Postpartum Onset
Bipolar disorder with episode not meeting full criteria, specifiers
In Partial Remission, In Full Remission (see page 411)

With Catatonic Features (see page 417)

With Postpartum Onset
If bipolar disorder with criteria met for MDE, specifiers
Chronic (see page 417)

With Melancholic Features (see page 419)

With Atypical Features
Pattern specifiers
With and Without Full Interepisode Recovery) (see page 424)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see page 425)

With Rapid Cycling
Catatonia definition
at least TWO of

(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor

(2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli)

(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism

(4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

(5) echolalia or echopraxia
Recording procedure for Bipolar I Disorder?
In recording the name of a diagnosis, terms should be listed in the following order:
1. Bipolar I Disorder,
2. specifiers coded in the fourth digit (e.g., Most Recent Episode Manic), 3. specifiers coded in the fifth digit (e.g., Mild, Severe With Psychotic Features, In Partial Remission), as 4. many specifiers (without codes) as apply to the current or most recent episode (e.g., With Melancholic Features, With Postpartum Onset), and as many specifiers (without codes) as apply to the
5. course of episodes (e.g., With Rapid Cycling);

for example, 296.54 Bipolar I Disorder, Most Recent Episode Depressed, Severe With Psychotic Features, With Melancholic Features, With Rapid Cycling.
Completed suicide occurs in XX% of individuals with Bipolar I Disorder.
10 to 15%
Common associated mental disorders with bipolar disorder
Substance Use Disorders
Eating DS
ADHD
Anxiety Ds
Bipolar ds and key GMC to consider?
Thyroid disease; i.e., hyperthyroidism
Gender difference in BP I ds?
Equal among men and women (MDD > in women); However, first episode in males more likely to be Mania while in women Depression
In addition, Rapid Cycling (see page 427) is more common in (SEX?)
women
The lifetime prevalence of Bipolar I Disorder in community samples has varied from XX to XX?
0.4% to 1.6%
Age of onset
around 20 for men and women
Bipolar I Disorder is a recurrent disorder—more than XX% of individuals who have a single Manic Episode go on to have future episodes
90
The number of lifetime episodes (both Manic and Major Depressive) tends to be (LOWER OR HIGHER?) for Bipolar I Disorder compared with Major Depressive Disorder, Recurrent
HIGHER
Studies of the course of Bipolar I Disorder prior to lithium maintenance treatment suggest that, on average, XX episodes occur in 10 years
4
pproximately XX% of individuals with Bipolar I Disorder have multiple (YY or more) mood episodes (Major Depressive, Manic, Mixed, or Hypomanic) that occur within a given year. If this pattern is present, it is noted by the specifier With ZZ
5 to 15%
Four
With Rapid Cycling
First-degree biological relatives of individuals with Bipolar I Disorder have elevated rates of Bipolar I Disorder (XX%), Bipolar II Disorder (YY%), and Major Depressive Disorder (ZZ%
4 to 24%
1-5%
4 to 24%
How Distinguish BP vs Psychotic Ds
In contrast to Bipolar I Disorder, Schizophrenia, Schizoaffective Disorder, and Delusional Disorder are all characterized by

periods of psychotic symptoms that occur in the absence of prominent mood symptoms
Manic Episode 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. The symptoms do not meet criteria for a Mixed Episode (see page 365).
D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
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).
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.
Mixed Episode Criteria
A. The criteria are met both for a Manic Episode (see page 362) and for a Major Depressive Episode (see page 356) (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 to necessitate hospitalization to prevent harm to self or 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, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.
Hypomanic Episode 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 nondepressed mood.
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.
Is improved mood after mde, hypomania?
Hypomanic Episodes should not be confused with the several days of euthymia that may follow remission of a Major Depressive Episode.
BP2 Suicide Risk?
Completed suicide (usually during Major Depressive Episodes) is a significant risk, occurring in 10%-15% of persons with Bipolar II Disorder.
BP2 associated disorders?
Substance Ds, Eating, ADHD, Anxiety and Borderline PD
BP2 gender difference?
Yes, Bipolar II Disorder may be more common in women than in men.

In men the number of Hypomanic Episodes equals or exceeds the number of Major Depressive Episodes, whereas in women Major Depressive Episodes predominate
For BP, Rapid Cycling (see page 427) is more common in (GENDER)
women
Community studies suggest a lifetime prevalence of Bipolar II Disorder of approximately XX%
0.5%
Important Cyclothymia Exclusion Criteria?
The diagnosis of Cyclothymic Disorder is made only if the initial 2-year period of cyclothymic symptoms is free of Major Depressive, Manic, and Mixed Episodes (Criterion C).
Sx Free period less than 2 months
Studies have reported a lifetime prevalence of Cyclothymic Disorder of from XX%. Prevalence in mood disorders clinics may range from YY
0.4 to 1%
3 to 5%
Melancholic Features specifier criteria?
A. Either of the following, occurring during the most severe period of the current episode:
(1) loss of pleasure in all, or almost all, activities
(2) lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens)

B. Three (or more) of the following:
(1) distinct quality of depressed mood (i.e., the depressed mood is experienced as distinctly different from the kind of feeling experienced after the death of a loved one)
(2) depression regularly worse in the morning
(3) early morning awakening (at least 2 hours before usual time of awakening)
(4) marked psychomotor retardation or agitation
(5) significant anorexia or weight loss
(6) excessive or inappropriate guilt
Melancholic Mnemonic?
PAGER MAD
Psychomotor changes are marked
anorexia or weight loss
Guilt is excessive
Early morning awakening
Reactivity is lacking to stimuli
Morning depression is regularly worse
Anhedonia
Distinct qualty of depressed mood
Atypical Features Specifier for MDE?
A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events)
B. Two (or more) of the following features:
(1) significant weight gain or increase in appetite
(2) hypersomnia
(3) leaden paralysis (i.e., heavy, leaden feelings in arms or legs)
(4) long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment

C. Criteria are not met for With Melancholic Features or With Catatonic Features during the same episode.
Atpical Features mnemonic
RAILS
Reactivity of mood
Appetite increases
Interpersonal rejectionsensitivity
Leaden paralysis
Sleep is increased