47 - Elimination Disorders

Authors: Sadock, Benjamin James; Sadock, Virginia Alcott

Title: Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition

Copyright ©2007 Lippincott Williams & Wilkins

> Table of Contents > 15 - Mood Disorders > 15.3 - Other Mood Disorders

15.3

Other Mood Disorders

Depressive Disorder not Otherwise Specified

The diagnostic category, depressive disorder not otherwise specified, is used for patients who exhibit depressive symptoms as the major feature, but who do not meet the diagnostic criteria for any other mood disorder (Table 15.3-1). Three disorders meet this criterion: (1) minor depressive disorder, (2) recurrent brief depressive disorder, and (3) premenstrual dysphoric disorder.

Minor Depressive Disorder

The literature in the United States on minor depressive disorder is limited, in part, because the term is used to describe a wide range of disorders, including dysthymic disorder, which is listed as a diagnosis in the text revision of the fourth revised edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).

Epidemiology

Minor depressive disorder may be as common as major depressive disorder—that is, about 5 percent prevalence in the general population. The disorder is more common in women than in men and affects people of virtually any age, from childhood onward.

Etiology

The cause of minor depressive disorder is unknown. Both biological and psychological factors are implicated.

Diagnosis and Clinical Features

The criteria for minor depressive disorder include symptoms equal in duration to those of major depressive disorder, but less severe (Table 15.3-2). The central symptom of both disorders is the same—a depressed mood.

Differential Diagnosis

The differential diagnosis of minor depressive disorder includes dysthymic disorder and recurrent brief depressive disorder. Dysthymic disorder is characterized by the presence of chronic depressive symptoms, whereas recurrent brief depressive disorder is characterized by multiple brief episodes of severe depressive symptoms.

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Table 15.3-1 DSM-IV-TR Diagnostic Criteria for Depressive Disorder Not Otherwise Specified

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 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.
  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 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.
(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.)

Course and Prognosis

No definitive data on the course and the prognosis of minor depressive disorder are available, but minor depressive disorder, as with major depressive disorder, has a long-term course that requires long-term treatment. Some cases remit spontaneously, however.

Treatment

The treatment of minor depressive disorder can include psychotherapy, pharmacotherapy, or both. Insight-oriented psychotherapy, cognitive therapy, interpersonal therapy, and behavior therapy are the psychotherapeutic treatments for major depressive disorder and, by implication, for minor depressive disorder. Patients with minor depressive disorder are probably responsive to pharmacotherapy, particularly selective serotonin reuptake inhibitors (SSRIs) and bupropion (Wellbutrin).

Recurrent Brief Depressive Disorder

Recurrent brief depressive disorder is characterized by multiple, relatively brief episodes (less than 2 weeks) of depressive symptoms that, except for their brief duration, meet the diagnostic criteria for major depressive disorder.

Epidemiology

The 10-year prevalence rate for the disorder is estimated to be 10 percent for people in their 20s; the 1-year prevalence rate for the general population is estimated to be 5 percent. These numbers indicate that recurrent brief depressive disorder is most common among young adults.

Table 15.3-2 DSM-IV-TR Research Criteria for Minor Depressive Disorder

  1. A mood disturbance, defined as follows:
    1. at least two (but less than five) 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 (a) or (b):
      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 suicide
    2. the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
    3. 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)
    4. the symptoms are not better accounted for by bereavement (i.e., a normal reaction to the death of a loved one)
  2. There has never been a major depressive episode, and criteria are not met for dysthymic disorder.
  3. There has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria are not met for cyclothymic disorder. Note: This exclusion does not apply if all of the manic-, mixed-, or hypomanic-like episodes are substance or treatment induced.
  4. The mood disturbance does not occur exclusively during schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, or psychotic disorder not otherwise specified.
(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.)

Etiology

Patients with recurrent brief depressive disorder may share several biological abnormalities with patients with

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major depressive disorder. The variables include nonsuppression on the dexamethasone-suppression test (DST), a blunt response to thyrotropin-releasing hormone (TRH), and a shortening of rapid eye movement (REM) sleep latency. The data are consistent with the idea that recurrent brief depressive disorder is closely related to major depressive disorder in its cause and pathophysiology.

Table 15.3-3 DSM-IV-TR Research Criteria for Recurrent Brief Depressive Disorder

  1. Criteria, except for duration, are met for a major depressive episode.
  2. The depressive periods in Criterion A last at least 2 days but less than 2 weeks.
  3. The depressive periods occur at least once a month for 12 consecutive months and are not associated with the menstrual cycle.
  4. The periods of depressed mood cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  5. 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).
  6. There has never been a major depressive episode, and criteria are not met for dysthymic disorder.
  7. There has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria are not met for cyclothymic disorder. Note: This exclusion does not apply if all of the manic-, mixed-, or hypomanic-like episodes are substance or treatment induced.
  8. The mood disturbance does not occur exclusively during schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, or psychotic disorder not otherwise specified.
(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.)

Diagnosis and Clinical Features

The criteria for recurrent brief depressive disorder specify that the symptom duration for each episode is less than 2 weeks (Table 15.3-3). Otherwise, the diagnostic criteria for recurrent brief depressive disorder and major depressive disorder are essentially identical. One subtle difference is that the frequent changes in their moods may make the lives of patients with recurrent brief depressive disorder seem more disrupted or chaotic than those of patients with major depressive disorder, whose depressive episodes occur at a measured pace.

Differential Diagnosis

Clinicians should consider bipolar disorder and major depressive disorder with seasonal pattern in the differential diagnosis. Recurrent brief depressive disorder can be associated with the rapid cycling type of bipolar disorder. Clinicians should also determine whether a seasonal pattern exists to the recurrence of depressive episodes.

Course and Prognosis

The course, including age of onset, and prognosis are similar to major depressive disorder.

Treatment

The treatment of patients with recurrent brief depressive disorder should be similar to the treatment of patients with major depressive disorder. Some of the treatments for bipolar I disorder—lithium (Eskalith) and anticonvulsants—may be of therapeutic value.

Premenstrual Dysphoric Disorder

Premenstrual dysphoric disorder is also called late luteal phase dysphoric disorder. The syndrome involves mood symptoms (e.g., lability), behavior symptoms (e.g., changes in eating patterns), and physical symptoms (e.g., breast tenderness, edema, and headaches). This pattern of symptoms occurs at a specific time during the menstrual cycle, and the symptoms resolve for some period of time between menstrual cycles. (Chapter 30 provides an extensive overview of this and other disorders related to the reproductive cycle.)

Postpsychotic Depressive Disorder of Schizophrenia

Postpsychotic depressive disorder in patients with schizophrenia is categorized in an appendix in DSM-IV-TR.

Epidemiology

The reported incidence of postpsychotic depression of schizophrenia varies widely, from less than 10 percent to more than 70 percent.

Etiology

The etiology is unknown. Psychologically, some patients became depressed after realizing their vulnerability to mental illness, which lowers their self-esteem.

Prognostic Significance

Patients with postpsychotic depressive disorder of schizophrenia are likely to have had poor premorbid adjustment, marked schizoid personality disorder traits, and an insidious onset of their psychotic symptoms. They are also likely to have first-degree relatives with mood disorders. Although the findings have not been consistent, postpsychotic depressive disorder of schizophrenia has been associated with a less-favorable prognosis, a higher likelihood of relapse, and a higher incidence of suicide than is seen in patients with schizophrenia without postpsychotic depressive disorder.

Diagnosis and Differential Diagnosis

The symptoms of postpsychotic depressive disorder of schizophrenia can closely resemble the symptoms of the residual phase of schizophrenia as well as the adverse effects of commonly used antipsychotic medications. Clinicians should not confuse the antipsychotic-induced adverse effects of akathisia and akinesia with symptoms of postpsychotic depressive disorder. Distinguishing the diagnosis from schizoaffective disorder, depressive type, is also difficult (Table 15.3-4).

Treatment

The use of antidepressants is indicated in the treatment of postpsychotic depressive disorder of schizophrenia, but response rates vary and are unpredictable.

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Table 15.3-4 DSM-IV-TR Research Criteria for Postpsychotic Depressive Disorder of Schizophrenia

  1. Criteria are met for a major depressive episode.
    Note: The major depressive episode must include Criterion A1: depressed mood. Do not include symptoms that are better accounted for as medication side effects or negative symptoms of schizophrenia.
  2. The major depressive episode is superimposed on and occurs only during the residual phase of schizophrenia.
  3. The major depressive episode is not due to the direct physiological effects of a substance or a general medical condition.
(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.)

Bipolar Disorder not Otherwise Specified

If patients exhibit depressive and manic symptoms as the major features of their disorder and do not meet the diagnostic criteria for any other mood disorder or other DSM-IV-TR mental disorder, the most appropriate diagnosis is bipolar disorder not otherwise specified (Table 15.3-5). This category should be used rarely.

Mixed Anxiety-Depressive Disorder

Mixed anxiety-depressive disorder is characterized by a persistent or recurrent depressed mood lasting at least 1 month and by symptoms of anxiety, such as sleep disturbance, fatigue or low energy, irritability, and worry (Table 15.3-6). The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Table 15.3-5 DSM-IV-TR Diagnostic Criteria for Bipolar Disorder Not Otherwise Specified

The bipolar disorder not otherwise specified category includes disorders with bipolar features that do not meet criteria for any specific bipolar disorder. Examples include
  1. Very rapid alternation (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
  2. Recurrent hypomanic episodes without intercurrent depressive symptoms
  3. A manic or mixed episode superimposed on delusional disorder, residual schizophrenia, or psychotic disorder not otherwise specified
  4. Hypomanic episodes, along with chronic depressive symptoms, that are too infrequent to qualify for a diagnosis of cyclothymic disorder
  5. Situations in which the clinician has concluded that a bipolar disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced
(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.)

Table 15.3-6 Research Criteria for Mixed Anxiety-Depressive Disorder

  1. Persistent or recurrent dysphoric mood lasting at least 1 month.
  2. The dysphoric mood is accompanied by at least 1 month of four (or more) of the following symptoms:
    1. difficulty concentrating or mind going blank
    2. sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
    3. fatigue or low energy
    4. irritability
    5. worry
    6. being easily moved to tears
    7. hypervigilance
    8. anticipating the worst
    9. hopelessness (pervasive pessimism about the future)
    10. low self-esteem or feelings of worthlessness
  3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. 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.
  5. All of the following:
    1. criteria have never been met for Major Depressive Disorder, Dysthymic Disorder, Panic Disorder, or Generalized Anxiety Disorder
    2. criteria are not currently met for any other Anxiety or Mood Disorder (including an Anxiety or Mood Disorder, In Partial Remission)
    3. the symptoms are not better accounted for by any other mental disorder
(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington DC: American Psychiatric Association; copyright 2000, with permission.)

Patients with mixed pictures are reportedly most prevalent in general medical settings because they have many somatic complaints about which they are anxious, one of the most prominent being chronic fatigue. In the 10th revision of International Statistical Classification of Diseases and Related Health Problems (ICD-10), these patients are diagnosed with neurasthenia. Some patients with chronic fatigue syndrome also have mixed anxiety and depressive symptomatology. This disorder is also discussed more fully in Chapter 18, which covers neurasthenia and chronic fatigue syndrome.

Atypical Depression

Atypical depression refers to fatigue superimposed on a history of somatic anxiety and phobias, together with reverse vegetative signs (mood worse in the evening, insomnia, tendency to oversleep and overeat), so that weight gain occurs rather than weight loss. Sleep is disturbed in the first half of the night in many persons with atypical depressive disorder, so irritability, hypersomnolence, and daytime fatigue would be expected. The temperaments of these patients are characterized by extreme sensitivity, especially to rejection. SSRIs and monoamine oxidase inhibitors (MAOIs) seem to show some specificity for such patients. Others are helped by psychostimulants, such as amphetamine.

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Other Disorders not Included in DSM-IV-TR

Several disorders with mood changes are not part of the official DSM nosological system. Some are included in the European diagnostic system and are found in the ICD-10.

Hysteroid Dysphoria

The category of non-DSM hysteroid dysphoria combines reverse vegetative signs with the following characteristics: (1) giddy responses to romantic opportunities and an avalanche of dysphoria (angry-depressive, even suicidal responses) on romantic disappointment; (2) impaired anticipatory pleasure, yet the capability to respond with pleasure when such is provided by others (i.e., preservation of consummatory reward); (3) craving for chocolate and sweets, which contain phenylethylamine compounds and sugars believed to facilitate cellular and neuronal intake of the amino acid L-tryptophan, hypothetically leading to synthesis of endogenous antidepressants in the brain. The word hysteroid was used to imply that the apparent character pathology was secondary to biological disturbances. Patients are treated symptomatically. Some respond to SSRIs, others to MAOIs and mood stabilizers, such as carbamazepine. This is not an “official” DSM-IV-TR diagnosis; it can be considered an atypical variant of depression.

Table 15.3-7 DSM-IV-TR Diagnostic Criteria for Mood Disorder Due to a General Medical Condition

  1. 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
  2. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
  3. 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).
  4. The disturbance does not occur exclusively during the course of a delirium.
  5. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify type:
   With depressive features: if the predominant mood is depressed but the full criteria are not met for a major depressive episode
   With major depressive-like episode: 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, e.g., mood disorder due to hypothyroidism, with depressive features; 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, i.e., vascular dementia, with depressed mood.
(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.)

Table 15.3-8 Pharmacological Causes of Depression

  1. Cardiac and antihypertensive drugs
  2. Sedatives and hypnotics
  3. Steroids and hormones
  4. Stimulants and appetite suppressants
  5. Psychotropic drugs
  6. Neurological agents
  7. Analgesics and anti-inflammatory drugs
  8. Antibacterial and antifungal drugs
  9. Antineoplastic drugs
  10. Nonsteroidal anti-inflammatory drugs (NSAIDs)
  11. Anticholinesterases

Motility Psychosis

The two forms of motility psychosis are akinetic and hyperkinetic. The akinetic form of motility psychosis has a clinical presentation similar to that of catatonic stupor. In contrast to the catatonic type of schizophrenia, however, akinetic motility psychosis has a rapidly resolving and favorable course that does not lead to personality deterioration. In its hyperkinetic form, motility psychosis can resemble manic or catatonic excitement. As with the akinetic form, the hyperkinetic form usually has a rapidly resolving and favorable course. Patients may switch from the akinetic to hyperkinetic form rapidly and may represent a danger to others during the excited phase. Mood is extremely labile in these patients. Motility psychosis is probably a variant of brief psychotic disorder.

Confusional Psychosis

As described originally, excited confusional psychosis is similar to mania, but was differentiated from mania by several characteristics: more anxiety, less distractibility, and a degree of speech incoherence out of proportion to the severity of the flight of ideas. Confusional psychosis

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is probably a clinical variation of the mania seen in bipolar I disorder. Patients may switch rapidly from the akinetic to the hyperkinetic form and may represent a danger to others during the excited phase.

Table 15.3-9 Some Pharmacological Causes of Mania

Amphetamines
Baclofen
Bromide
Bromocriptine
Captopril
Cimetidine
Cocaine
Corticosteroids (including adrenocorticoid hormone [ACTH])
Cyclosporine
Disulfiram
Hallucinogens (intoxication and flashbacks)
Hydralazine
Isoniazid
Levodopa
Methylphenidate
Metrizamide (following myelography)
Opiates and opioids
Phencyclidine (PCP)
Procarbazine
Procyclidine
Yohimbine
(Adapted from Cummings JL. Clinical Neuropsychiatry. Orlando, FL: Grune & Stratton; 1985:187, with permission.)

Table 15.3-10 DSM-IV-TR Diagnostic Criteria for Substance-Induced Mood Disorder

  1. 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
  2. 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
  3. 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 type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non–substance-induced mood disorder (e.g., a history of recurrent major depressive episodes).
  4. The disturbance does not occur exclusively during the course of a delirium.
  5. 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 independent clinical attention. Code [Specific substance]-induced mood disorder:
   Alcohol; amphetamine [or amphetamine-like substance]; cocaine; hallucinogen; inhalant; opioid; phencyclidine [or phencyclidine-like substance]; sedative, hypnotic, or anxiolytic; 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 predominates
Specify if:
   With onset during intoxication: if the criteria are met for intoxication with the substance and the symptoms develop during the intoxication syndrome
   With onset during withdrawal: if criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, a withdrawal syndrome
(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.)

Anxiety-Blissfulness Psychosis

Anxiety-blissfulness psychosis may resemble agitated depression but can also be characterized by so much inhibition that a patient can hardly move. Periodic states of overwhelming anxiety and paranoid ideas of reference are characteristic of the condition, but self-accusation, hypochondriacal preoccupation, other depressive symptoms, and hallucinations may also accompany it. The blissful phase manifests most frequently in expansive behavior and grandiose ideas, which are concerned less with self-aggrandizement than with the mission of making others happy and saving the world.

Secondary Mood Disorders

Secondary mood disorders consist of two broad categories that must be considered in the differential diagnosis of any patient with mood disorder symptoms. They are (1) mood disorder caused by a general medical condition and (2) substance-induced mood disorder.

Mood Disorders Due to a General Medical Condition

When depressive or manic symptoms are present in a patient with a general medical condition, attributing the depressive symptoms either to the general medical condition or to a mood disorder can be difficult. Many general medical conditions present depressive symptoms, such as poor sleep, agitation, decreased appetite, increased appetite, and fatigue. Table 15.3-7 lists the DSM-IV-TR criteria for the disorder. This category is discussed extensively in Section 10.5.

Substance-Induced Mood Disorder

Substance-induced mood disorder must always be considered in the differential diagnosis of mood disorder symptoms. Clinicians should consider three possibilities: (1) a patient may be taking drugs for the treatment of nonpsychiatric medical problems; (2) a patient may have been accidentally, and perhaps unknowingly, exposed to neurotoxic chemicals; and (3) the patient may have taken a substance for recreational purposes or may be dependent on such a substance.

Table 15.3-11 DSM-IV-TR Diagnostic Criteria for Mood Disorder Not Otherwise Specified

This category includes 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).
(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.)

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Table 15.3-12 ICD-10 Diagnostic Criteria for Mood [Affective] Disorders

Manic episode
Hypomania
  1. The mood is elevated or irritable to a degree that is definitely abnormal for the individual concerned and sustained for at least 4 consecutive days.
  2. At least three of the following signs must be present, leading to some interference with personal functioning in daily living:
    1. increased activity or physical restlessness;
    2. increased talkativeness;
    3. distractibility or difficulty in concentration;
    4. decreased need for sleep;
    5. increased sexual energy;
    6. mild overspending, or other types of reckless or irresponsible behavior;
    7. increased sociability or overfamiliarity.
  3. The episode does not meet the criteria for mania, bipolar affective disorder, depressive episode, cyclothymia, or anorexia nervosa.
  4. Most commonly used exclusion clause. The episode is not attributable to psychoactive substance use or to any organic mental disorder.
Mania without psychotic symptoms
  1. Mood must be predominantly elevated, expansive, or irritable, and definitely abnormal for the individual concerned. The mood change must be prominent and sustained for at least 1 week (unless it is severe enough to require hospital admission).
  2. At least three of the following signs must be present (four if the mood is merely irritable), leading to severe interference with personal functioning in daily living:
    1. increased activity or physical restlessness;
    2. increased talkativeness (“pressure of speech”);
    3. flight of ideas or the subjective experience of thoughts racing;
    4. loss of normal social inhibitions, resulting in behavior that is inappropriate to the circumstances;
    5. decreased need for sleep;
    6. inflated self-esteem or grandiosity;
    7. distractibility or constant changes in activity or plans;
    8. behavior that is foolhardy or reckless and whose risks the individual does not recognize, e.g., spending sprees, foolish enterprises, reckless driving;
    9. marked sexual energy or sexual indiscretions.
  3. There are no hallucinations or delusions, although perceptual disorders may occur (e.g., subjective hyperacusis, appreciation of colors as especially vivid).
  4. Most commonly used exclusion clause. The episode is not attributable to psychoactive substance use or to any organic mental disorder.
Mania with psychotic symptoms
  1. The episode meets the criteria for mania without psychotic symptoms with the exception of Criterion C.
  2. The episode does not simultaneously meet the criteria for schizophrenia or schizoaffective disorder, manic type.
  3. Delusions or hallucinations are present, other than those listed as typically schizophrenic in Criterion G1(1)b, c, and d for schizophrenia (i.e., delusions other than those that are completely impossible or culturally inappropriate, and hallucinations that are not in the third person or giving a running commentary). The commonest examples are those with grandiose, self-referential, erotic, or persecutory content.
  4. Most commonly used exclusion clause. The episode is not attributable to psychoactive substance use or to any organic mental disorder.
Specify whether the hallucinations or delusions are congruent or
incongruent with the mood:
   With mood-congruent psychotic symptoms (such as grandiose delusions or voices telling the individual that he or she has superhuman powers)
   With mood-incongruent psychotic symptoms (such as voices speaking to the individual about affectively neutral topics, or delusions of reference or persecution)
Other manic episodes
Manic episode, unspecified
Bipolar affective disorder
Note. Episodes are demarcated by a switch to an episode of opposite mixed polarity or by a remission.
Bipolar affective disorder, current episode hypomanic
  1. The current episode meets the criteria for hypomania.
  2. There has been at least one other affective episode in the past, meeting the criteria for hypomanic or manic episode, depressive episode, or mixed affective episode.
Bipolar affective disorder, current episode manic without psychotic symptoms
  1. The current episode meets the criteria for mania without psychotic symptoms.
  2. There has been at least one other affective episode in the past, meeting the criteria for hypomanic or manic episode, depressive episode, or mixed affective episode.
Bipolar affective disorder, current episode manic without psychotic symptoms
  1. The current episode meets the criteria for mania without psychotic symptoms.
  2. There has been at least one other affective episode in the past, meeting the criteria for hypomanic or manic episode, depressive episode, or mixed affective episode.
Specify whether the psychotic symptoms are congruent or incongruent with the mood:
   With mood-congruent psychotic symptoms
   With mood-incongruent psychotic symptoms
Bipolar affective disorder, current episode moderate or mild depression
  1. The current episode meets the criteria for a depressive episode of either mild or moderate severity.
  2. There has been at least one other affective episode in the past, meeting the criteria for hypomanic or manic episode, depressive episode, or mixed affective episode.
   Specify the presence of the “somatic syndrome” in the current episode of depression:
   Without somatic syndrome
   With somatic syndrome
Bipolar affective disorder, current episode severe depression without psychotic symptoms
  1. The current episode meets the criteria for a severe depressive episode without psychotic symptoms.
  2. There has been at least one well-authenticated hypomanic or manic episode or mixed affective episode in the past.
Bipolar affective disorder, current episode severe depression with psychotic symptoms
  1. The current episode meets the criteria for a severe depressive episode without psychotic symptoms.
  2. There has been at least one well-authenticated hypomanic or manic episode or mixed affective episode in the past.
Specify whether the psychotic symptoms are congruent or incongruent with the mood:
   With mood-congruent psychotic symptoms
   With mood-incongruent psychotic symptoms
Bipolar affective disorder, current episode mixed
  1. The current episode is characterized by either a mixture or a rapid alternation (i.e., within a few hours) of hypomanic, manic, and depressive symptoms.
  2. Both manic and depressive symptoms must be prominent most of the time during a period of at least 2 weeks.
  3. There has been at least one well-authenticated hypomanic or manic episode, depressive episode, or mixed affective episode in the past.
Bipolar affective disorder, currently in remission
  1. The current state does not meet the criteria for depressive or manic episode of any severity or for any other mood [affective] disorder (possibly because of treatment to reduce the risk of future episodes).
  2. There has been at least one well-authenticated hypomanic or manic episode in the past and in addition at least one other affective episode (hypomanic or manic, depressive, or mixed).
Other bipolar affective disorders
Bipolar affective disorder, unspecified
Depressive episode
G1. The depressive episode should last for at least 2 weeks.
G2. There have been no hypomanic or manic symptoms sufficient to meet the criteria for hypomanic or manic episode at any time in the individual's life.
G3. Most commonly used exclusion clause. The episode is not attributable to psychoactive substance use or to any organic mental disorder.
Somatic syndrome
Some depressive symptoms are widely regarded as having special clinical significance and are here called “somatic.” (Terms such as biological, vital, melancholic, or endogenomorphic are used for this syndrome in other classifications.)
A fifth character may be used to specify the presence or absence of the somatic syndrome. To qualify for the somatic syndrome, four of the following symptoms should be present:
  1. marked loss of interest or pleasure in activities that are normally pleasurable;
  2. lack of emotional reactions to events or activities that normally produce an emotional response;
  3. waking in the morning 2 hours or more before the usual time;
  4. depression worse in the morning;
  5. objective evidence of marked psychomotor retardation or agitation (remarked on or reported by other people);
  6. marked loss of appetite;
  7. weight loss (5% or more of body weight in the past month);
  8. marked loss of libido.
In The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines, the presence or absence of the somatic syndrome is not specified for severe depressive episode, since it is presumed to be present in most cases. For research purposes, however, it may be advisable to allow for the coding of the absence of the somatic syndrome in severe depressive episode.
Mild depressive episode
  1. The general criteria for depressive episode must be met.
  2. At least two of the following three symptoms must be present:
    1. depressed mood to a degree that is definitely abnormal for the individual, present for most of the day and almost every day, largely uninfluenced by circumstances, and sustained for at least 2 weeks;
    2. loss of interest or pleasure in activities that are normally pleasurable;
    3. decreased energy or increased fatigability.
  3. An additional symptom or symptoms from the following list should be present, to give a total of at least four:
    1. loss of confidence or self-esteem;
    2. unreasonable feelings of self-reproach or excessive and inappropriate guilt;
    3. recurrent thoughts of death or suicide, or any suicidal behavior;
    4. complaints or evidence of diminished ability to think or concentrate, such as indecisiveness or vacillation;
    5. change in psychomotor activity, with agitation or retardation (either subjective or objective);
    6. sleep disturbance of any type;
    7. change in appetite (decrease or increase) with corresponding weight change.
A fifth character may be used to specify the presence or absence of the “somatic syndrome”:
   Without somatic syndrome
   With somatic syndrome
Moderate depressive episode
  1. The general criteria for depressive episode must be met.
  2. At least two of the three symptoms listed for Criterion B above must be present.
  3. Additional symptoms from depressive episode, Criterion C, must be present, to give a total of at least six.
A fifth character may be used to specify the presence or absence of the “somatic syndrome”:
   Without somatic syndrome
   With somatic syndrome
Severe depressive episode without psychotic symptoms
Note: If important symptoms such as agitation or retardation are marked, the patient may be unwilling or unable to describe many symptoms in detail. An overall grading of severe episode may still be justified in such a case.
  1. The general criteria for depressive episode must be met.
  2. All three of the symptoms in Criterion B, depressive episode, must be present.
  3. Additional symptoms from depressive episode, Criterion C, must be present, to give a total of at least eight.
  4. There must be no hallucinations, delusions, or depressive stupor.
Severe depressive episode with psychotic symptoms
  1. The general criteria for depressive episode must be met.
  2. The criteria for severe depressive episode without psychotic symptoms must be met with the exception of Criterion D.
  3. The criteria for schizophrenia or schizoaffective disorder, depressive type, are not met.
  4. Either of the following must be present:
    1. delusions or hallucinations, other than those listed as typically schizophrenic in Criterion G1(1)b, c, and d for general criteria for paranoid, hebephrenic, catatonic, and undifferentiated schizophrenia (i.e., delusions other than those that are completely impossible or culturally inappropriate and hallucinations that are not in the third person or giving a running commentary), the commonest examples are those with depressive, guilty, hypochondriacal, nihilistic, self-referential, or persecutory content
    2. depressive stupor
A fifth character may be used to specify whether the psychotic symptoms are congruent or incongruent with mood:
   With mood-congruent psychotic symptoms (i.e., delusions of guilt, worthlessness, bodily disease, or impending disaster, derisive or condemnatory auditory hallucinations)
   With mood-incongruent psychotic symptoms (i.e., persecutory or self-referential delusions and hallucinations without an affective content)
Other depressive episodes
Episodes should be included here which do not fit the descriptions given for depressive episodes, but for which the overall diagnostic impression indicates that they are depressive in nature. Examples include fluctuating mixtures of depressive symptoms (particularly those of the somatic syndrome) with nondiagnostic symptoms such as tension, worry, and distress, and mixtures of somatic depressive symptoms with persistent pain or fatigue not due to organic causes (as sometimes seen in general hospital services).
Depressive episode, unspecified
Recurrent depressive disorder
G1. There has been at least one previous episode, mild, moderate, or severe, lasting a minimum of 2 weeks and separated from the current episode by at least 2 months free from any significant mood symptoms.
G2. At no time in the past has there been an episode meeting the criteria for hypomanic or manic episode.
G3. Most commonly used exclusion clause. The episode is not attributable to psychoactive substance use or to any organic mental disorder.
It is recommended that the predominant type of previous episodes is specified (mild, moderate, severe, uncertain).
Recurrent depressive disorder, current episode mild
  1. The general criteria for recurrent depressive disorder are met.
  2. The current episode meets the criteria for mild depressive episode.
A fifth character may be used to specify the presence or absence of the “somatic syndrome,” in the current episode:
   Without somatic syndrome
   With somatic syndrome
Recurrent depressive disorder, current episode moderate
  1. The general criteria for recurrent depressive disorder are met.
  2. The current episode meets the criteria for moderate depressive episode.
A fifth character may be used to specify the presence or absence of the “somatic syndrome.” in the current episode:
   Without somatic syndrome
   With somatic syndrome
Recurrent depressive disorder, current episode without psychotic symptoms
  1. The general criteria for recurrent depressive disorder are met.
  2. The current episode meets the criteria for severe depressive episode without psychotic symptoms.
Recurrent depressive disorder, current episode severe with psychotic symptoms
  1. The general criteria for recurrent depressive disorder are met.
  2. The current episode meets the criteria for severe depressive episode with psychotic symptoms.
A fifth character may be used to specify whether the psychotic symptoms are congruent or incongruent with the mood:
   With mood-congruent psychotic symptoms
   With mood-incongruent psychotic symptoms
Recurrent depressive disorder, currently in remission
  1. The general criteria for recurrent depressive disorder have been met in the past.
  2. The current state does not meet the criteria for a depressive episode of any severity or for any other disorder in mood [affective] disorders.
Comment
This category can still be used if the patient receives treatment to reduce the risk of further episodes.
Other recurrent depressive disorders
Recurrent depressive disorder, unspecified
Persistent mood [affective] disorders
Cyclothymia
  1. There must have been a period of at least 2 years of instability of mood involving several periods of both depression and hypomania, with or without intervening periods of normal mood.
  2. None of the manifestations of depression or hypomania during such a 2-year period should be sufficiently severe or long-lasting to meet criteria for manic episode or depressive episode (moderate or severe); however, manic or depressive episode(s) may have occurred before, or may develop after, such a period of persistent mood instability.
  3. During at least some of the periods of depression at least three of the following should be present:
    1. reduced energy or activity;
    2. insomnia;
    3. loss of self-confidence or feelings of inadequacy;
    4. difficulty in concentrating;
    5. social withdrawal;
    6. loss of interest in or enjoyment of sex and other pleasurable activities;
    7. reduced talkativeness;
    8. pessimism about the future or brooding over the past.
  4. During at least some of the periods of mood elevation at least three of the following should be present:
    1. increased energy or activity;
    2. decreased need for sleep;
    3. inflated self-esteem;
    4. sharpened or unusually creative thinking;
    5. increased gregariousness;
    6. increased talkativeness or wittiness;
    7. increased interest and involvement in sexual and other pleasurable activities;
    8. overoptimism or exaggeration of past achievements.
Note. If desired, time of onset may be specified as early (in late teenage or the 20s) or late (usually between age 30 and 50 years, following an affective episode).
Dysthymia
  1. There must be a period of at least 2 years of constant or constantly recurring depressed mood. Intervening periods of normal mood rarely last for longer than a few weeks, and there are no episodes of hypomania.
  2. None, or very few, of the individual episodes of depression within such a 2-year period should be sufficiently severe or long-lasting to meet the criteria for recurrent mild depressive disorder.
  3. During at least some of the periods of depression at least three of the following should be present:
    1. reduced energy or activity;
    2. insomnia;
    3. loss of self-confidence or feelings of inadequacy;
    4. difficulty in concentrating;
    5. frequent tearfulness;
    6. loss of interest in or enjoyment of sex and other pleasurable activities;
    7. feeling of hopelessness or despair;
    8. a perceived inability to cope with the routine responsibilities of everyday life;
    9. pessimism about the future or brooding over the past;
    10. social withdrawal;
    11. reduced talkativeness.

Note. If desired, time of onset may be specified as early (in late teenage or the 20s) or late (usually between age 30 and 50 years, following an affective episode).
Other persistent mood [affective] disorders
This is a residual category for persistent affective disorders that are not sufficiently severe or long-lasting to fulfill the criteria for cyclothymia or dysthymia but that are nevertheless clinically significant. Some types of depression previously called “neurotic” are included here, provided that they do not meet the criteria for either cyclothymia or dysthymia or for depressive episode of mild or moderate severity.
Persistent mood [affective] disorder, unspecified Other mood [affective] disorders
There are so many possible disorders that could be listed that no attempt has been made to specify criteria, except for mixed affective episode and recurrent brief depressive disorder. Investigators requiring criteria more exact than those available in Clinical Descriptions and Diagnostic Guidelines should construct them according to the requirements of their studies.
Other single mood [affective] disorders
Mixed affective episode
  1. The episode is characterized by either a mixture or a rapid alternation (i.e., within a few hours) of hypomanic, manic, and depressive symptoms.
  2. Both manic and depressive symptoms must be prominent most of the time during a period of at least 2 weeks.
  3. There is no history of previous hypomanic, depressive, or mixed episodes.
Other recurrent mood [affective] disorders
Recurrent brief depressive disorder
  1. The disorder meets the symptomatic criteria for mild, moderate, or severe depressive episode.
  2. The depressive episodes have occurred about once a month over the past year.
  3. The individual episodes last less than 2 weeks (typically 2–3 days).
  4. The episodes do not occur solely in relation to the menstrual cycle.
Other specified mood [affective] disorders
This is a residual category for affective disorders that do not meet the criteria for any other categories above.
(From World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research. Copyright, World Health Organization, Geneva, 1993, with permission.)

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Epidemiology

The epidemiology of substance-induced mood disorder is unknown. The prevalence is probably high, given the widespread use of so-called recreational drugs, the many prescription drugs that can cause depression and mania, and the toxic chemicals that abound in the environment and the workplace.

Etiology

A wide range of drugs can produce depression (Table 15.3-8) and mania (Table 15.3-9).

Diagnosis and Clinical Features

When making the diagnosis of substance-induced mood disorder, the clinician should specify the substance involved, the time of onset (during intoxication or withdrawal), and the nature of the symptoms (e.g., manic or depressed) (Table 15.3-10). A maximum of 1 month between the use of the substance and the appearance of the symptoms is allowed in DSM-IV-TR, but the timeframe is usually much shorter.

Substance-induced manic and depressive features can be identical to those of bipolar I disorder and major depressive disorder. Substance-induced mood disorder, however, may show more waxing and waning of symptoms and a fluctuation in a patient's level of consciousness.

Differential Diagnosis

A history of mood disorders in the patient or the patient's family weighs toward the diagnosis of a primary mood disorder, although such a history does not rule out the possibility of substance-induced mood disorder. Substances can also trigger an underlying mood disorder in a patient who is biologically vulnerable to mood disorders.

Course and Prognosis

The course and prognosis of substance-induced mood disorder vary. Shortly after the substance has been cleared from the body, a normal mood usually returns. Sometimes, however, the substance exposure seems to precipitate a long-lasting mood disorder that may take weeks or months to resolve completely.

Treatment

The primary treatment of substance-induced mood disorder is the identification of the causally involved substance. Stopping the intake of the substance usually suffices to cause the mood disorder symptoms to abate. If the symptoms linger, treatment with appropriate psychiatric drugs may be necessary.

Mood Disorder Not Otherwise Specified

If patients exhibit mood symptoms that are difficult to distinguish between depression and mania and do not meet the diagnostic criteria for any other mood disorder or other DSM-IV-TR mental disorder, the most appropriate diagnosis is mood disorder not otherwise specified (Table 15.3-11). Clinicians are encouraged to try to make a more specific diagnosis, however.

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ICD-10

The ICD-10 describes mood (affective) disorders as characterized by “a change in mood or affect, usually to depression (with or without associated anxiety) or to elation.” A change in activity level accompanies the mood change, and “most other symptoms are either secondary to, or easily understood in the context of, such changes.” These disorders are recurrent, and the onset of the episodes may be related to “stressful events or situations.” The mood disorders also include those occurring in children. Table 15.3-12 lists the ICD-10 criteria for mood disorders.

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