Initial Call

DSM-5 notes that issues related to genetics and symptoms locate bipolar disorders as a sort of bridge between mood disorders and schizophrenia. That’s why DSM-5 separated the deeply intertwined chapters on bipolar and depressive disorders. However, to explain mood disorders as clearly and concisely as possible, I’ve reunited them.

Quick Guide to the Mood Disorders

DSM-5 uses three groups of criteria sets to diagnose mental problems related to mood: (1) mood episodes, (2) mood disorders, and (3) specifiers describing most recent episode and recurrent course. I’ll cover each of them in this Quick Guide. As usual, the link refers to the point where a more detailed discussion begins.

Mood Episodes

Simply expressed, a mood episode refers to any period of time when a patient feels abnormally happy or sad. Mood episodes are the building blocks from which many of the codable mood disorders are constructed. Most patients with mood disorders (though not the majority of mood disorder types) will have one or more of these three episodes: major depressive, manic, and hypomanic. Without additional information, none of these mood episodes is a codable diagnosis.

Major depressive episode . For at least 2 weeks, the patient feels depressed (or cannot enjoy life) and has problems with eating and sleeping, guilt feelings, low energy, trouble concentrating, and thoughts about death.

Manic episode . For at least 1 week, the patient feels elated (or sometimes only irritable) and may be grandiose, talkative, hyperactive, and distractible. Bad judgment leads to marked social or work impairment; often patients must be hospitalized.

Hypomanic episode . This is much like a manic episode, but it is briefer and less severe. Hospitalization is not required.

Mood Disorders

A mood disorder is a pattern of illness due to an abnormal mood. Nearly every patient who has a mood disorder experiences depression at some time, but some also have highs of mood. 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 codable categories listed below.

DEPRESSIVE DISORDERS

Major depressive disorder . These patients have had no manic or hypomanic episodes, but have had one or more major depressive episodes. Major depressive disorder will be either recurrent or single episode.

Persistent depressive disorder (dysthymia) . There are no high phases, and it lasts much longer than typical major depressive disorder. This type of depression is not usually severe enough to be called an episode of major depression (though chronic major depression is now included here).

Disruptive mood dysregulation disorder . A child’s mood is persistently negative between frequent, severe explosions of temper.

Premenstrual dysphoric disorder . A few days before her menses, a woman experiences symptoms of depression and anxiety.

Depressive disorder due to another medical condition . A variety of medical and neurological conditions can produce depressive symptoms; these need not meet criteria for any of the conditions above.

Substance/medication-induced depressive disorder . Alcohol or other substances (intoxication or withdrawal) can cause depressive symptoms; these need not meet criteria for any of the conditions above.

Other specified, or unspecified, depressive disorder . Use one of these categories when a patient has depressive symptoms that do not meet the criteria for the depressive diagnoses above or for any other diagnosis in which depression is a feature.

BIPOLAR AND RELATED DISORDERS

Approximately 25% of patients with mood disorders experience manic or hypomanic episodes. Nearly all of these patients will also have episodes of depression. The severity and duration of the highs and lows determine the specific bipolar disorder.

Bipolar I disorder . There must be at least one manic episode; most patients with bipolar I have also had a major depressive episode.

Bipolar II disorder . This diagnosis requires at least one hypomanic episode plus at least one major depressive episode.

Cyclothymic disorder . These patients have had repeated mood swings, but none that are severe enough to be called major depressive episodes or manic episodes.

Substance/medication-induced bipolar disorder . Alcohol or other substances (intoxication or withdrawal) can cause manic or hypomanic symptoms; these need not meet criteria for any of the conditions above.

Bipolar disorder due to another medical condition . A variety of medical and neurological conditions can produce manic or hypomanic symptoms; these need not meet criteria for any of the conditions above.

Other specified, or unspecified, bipolar disorder . Use one of these categories when a patient has bipolar symptoms that do not meet the criteria for the bipolar diagnoses above.

Other Causes of Depressive and Manic Symptoms

Schizoaffective disorder . In these patients, symptoms suggestive of schizophrenia coexist with a major depressive or a manic episode.

Major and mild neurocognitive disorders with behavioral disturbance . The qualifier with behavioral disturbance can be coded into the diagnosis of major or mild neurocognitive disorder. OK, so mood symptoms don’t sound all that behavioral, but that’s how DSM-5 elects to indicate the cognitive disorders with depression.

Adjustment disorder with depressed mood . This term codes one way of adapting to a life stress.

Personality disorders . Dysphoric mood is specifically mentioned in the criteria for borderline personality disorder, but depressed mood commonly accompanies avoidant, dependent, and histrionic personality disorders.

Uncomplicated bereavement . Sadness at the death of a relative or friend is a common experience. Because uncomplicated bereavement is a normal reaction to a particular type of stressor, it is recorded not as a disorder, but as a Z-code [V-code]. See Z63.4 [V62.82] Uncomplicated Bereavement.

Other disorders. Depression can accompany many other mental disorders, including schizophrenia, the eating disorders, somatic symptom disorder, sexual dysfunctions, and gender dysphorias. Mood symptoms are likely in patients with an anxiety disorder (especially panic disorder and the phobic disorders), obsessive–compulsive disorder, and posttraumatic stress disorder.

Specifiers

Two special sets of descriptions can be applied to a number of the mood episodes and mood disorders.

SPECIFIERS DESCRIBING CURRENT OR MOST RECENT EPISODE

These descriptors help characterize the most recent major depressive episode; all but the first two can also apply to a manic episode. (Note that the specifiers for severity and remission are described later.)

With atypical features . These depressed patients eat a lot and gain weight, sleep excessively, and have a feeling of being sluggish or paralyzed. They are often excessively sensitive to rejection.

With melancholic features . This term applies to major depressive episodes characterized by some of the “classic” symptoms of severe depression. These patients awaken early, feeling worse than they do later in the day. They lose appetite and weight, feel guilty, are either slowed down or agitated, and do not feel better when something happens that they would normally like.

With anxious distress . A patient has symptoms of anxiety, tension, restlessness, worry, or fear that accompanies a mood episode.

With catatonic features . There are features of either motor hyperactivity or inactivity. Catatonic features can apply to major depressive episodes and to manic episodes.

With mixed features . Manic, hypomanic, and major depressive episodes may have mixtures of manic and depressive symptoms.

With peripartum onset . A manic, hypomanic, or major depressive episode (or a brief psychotic disorder) can occur in a woman during pregnancy or within a month of having a baby.

With psychotic features . Manic and major depressive episodes can be accompanied by delusions, which can be mood-congruent or -incongruent.

SPECIFIERS DESCRIBING COURSE OF RECURRING EPISODES

These specifiers describe the overall course of a mood disorder, not just the form of an individual episode.

With rapid cycling . Within 1 year, the patient has had at least four episodes (in any combination) fulfilling criteria for major depressive, manic, or hypomanic episodes.

With seasonal pattern . These patients regularly become ill at a certain time of the year, such as fall or winter.

INTRODUCTION TO MOOD EPISODES

Mood refers to a sustained emotion that colors the way we view life. Recognizing when mood is disordered is extremely important, because as many as 20% of adult women and 10% of adult men may have the experience at some time during their lives. The prevalence of mood disorders seems to be increasing in both sexes, accounting for half or more of a mental health practice. Mood disorders can occur in people of any race or socioeconomic status, but they are more common among those who are single and who have no “significant other.” A mood disorder is also more likely in someone who has relatives with similar problems.

The mood disorders encompass many diagnoses, qualifiers, and levels of severity. Although they may seem complicated, they can be reduced to a few main principles.

Years ago, the mood disorders were called affective disorders; many clinicians still use the older term, which is also entrenched in the name seasonal affective disorder. Note, by the way, that the term affect covers more than just a patient’s statement of emotion. It also encompasses how the patient appears to be feeling, as shown by physical clues such as facial expression, posture, eye contact, and tearfulness. Emphasis on the actual mood experience of the patient, rather than the sometimes fuzzy concept of affect, dictates the current use of mood.

In this section, I’ll describe three types of mood episodes. You will find case vignettes illustrating each one in the sections on the mood disorders themselves, which follow.