Initial Call 2
Table of Contents
Initial Call
Prior to beginning work on this discussion, please read Chapters 3, 4, and 17 in DSM-5 Made Easy: The Clinician’s Guide to Diagnosis; Case 20 from Case Studies in Abnormal Psychology; and Chapter 1 in Psychopathology: History, Diagnosis, and Empirical Foundations. It is recommended that you read Chapter 1 in Turning Points in Dynamic Psychotherapy: Initial Assessment, Boundaries, Money, Disruptions and Suicidal Crises.
For this discussion, you will choose a case study included in Case Studies in Abnormal Psychology.
In your initial post, you will take on the persona of the patient from the case study you have chosen in order to create an initial call to a mental health professional from the patient’s point of view. In order to create your initial call, evaluate the symptoms and presenting problems from the case study, and then determine how the patient would approach the first call.
Create a document that includes a transcript of a call from the patient’s point of view based on the information in the case study including basic personal information and reasons for seeking out psychotherapy. The call may be no more than 5 minutes in length. Once you have created your transcript you will create a screencast recording of the transcript using the patient’s voice. Based on the information from the case study, consider the following questions as you create your recording:
· What would the patient say?
· What tone of voice might he or she use?
· How fast would the patient speak?
· Would the message be understandable (e.g., would it be muffled, circumstantial, tangential, rambling, mumbled, pressured, etc.)?
You may use any screencasting software you choose. Quick-Start Guides are available Screencast-O-Matic (Links to an external site.)Links to an external site. for your convenience. Once you have created your screencast, include the link and the name of the case study you chose in your initial post and attach your transcript document prior to submitting it.
Resources:
Gorenstein, E., & Comer, J. (2015). Case studies in abnormal psychology (2nd ed.). New York, NY: Worth Publishers. ISBN: 9780716772736
Morrison, J. (2014). DSM-5 made easy: The clinician’s guide to diagnosis. New York, NY: The Guilford Press.
Craighead, W. E., Miklowitz, D. J., & Craighead, L. W. (2013). Psychopathology: History, diagnosis, and empirical foundations (2nd ed.). Hoboken, NJ: John Wiley & Sons. Retrieved from http://www.ebrary.com
Akhtar, S. (2009). Turning points in dynamic psychotherapy: Initial assessment, boundaries, money, disruptions and suicidal crises. London, England: Karnac Books. Retrieved from http://www.ebrary.com
CHAPTER 3
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.
Major Depressive Episode
Major depressive episode is one of the building blocks of the mood disorders, but it’s not a codable diagnosis. You will use it often—it is one of the most common problems for which patients seek help. Apply it carefully after considering a patient’s full history and mental status exam. (Of course, we should be careful in using every label and every diagnosis.) I mention this caution here because some clinicians tend to use the major depressive episode label almost as a reflex, without really considering the evidence. Once it gets applied, too often there is a reflexive reaching for the prescription pad.
A major depressive episode must meet five major requirements. There must be (1) a quality of depressed mood (or loss of interest or pleasure) that (2) has existed for a minimum period of time, (3) is accompanied by a required number of symptoms, (4) has resulted in distress or disability, and (5) violates none of the listed exclusions.
Quality of Mood
Depression is usually experienced as a mood lower than normal; patients may describe it as feeling “unhappy,” “downhearted,” “bummed,” “blue,” or many other terms expressing sadness. Several issues can interfere with the recognition of depression:
• Not all patients can recognize or accurately describe how they feel.
• Clinicians and patients who come from different cultural backgrounds may have difficulty agreeing that the problem is depression.
• The presenting symptoms of depression can vary greatly from one patient to another. One patient may be slowed down and crying; another will smile and deny that anything is wrong. Some sleep and eat too much; others complain of insomnia and anorexia.
• Some patients don’t really feel depressed; rather, they experience depression as a loss of pleasure or reduced interest in their usual activities, including sex.
• Crucial to diagnosis is that the episode must represent a noticeable change from the patient’s usual level of functioning. If the patient does not notice it (some are too ill to pay attention or too apathetic to care), family or friends may report that there has been such a change.
Duration
The patient must have felt bad most of the day, almost every day, for at least 2 weeks. This requirement is included to ensure that major depressive episodes are differentiated from the transient “down” spells that most of us sometimes feel.
Symptoms
During the 2 weeks just mentioned, the patient must have at least five of the italicized symptoms below. Those five must include either depressed mood or loss of pleasure, and the symptoms must overall indicate that the person is performing at a lower level than before. Depressed mood is self-explanatory; loss of pleasure is nearly universal among depressed patients. These symptoms can be counted either if the patient reports them or if others observe that they occur.
Many patients lose appetite and weight. More than three-fourths report trouble with sleep. Typically, they awaken early in the morning, long before it is time to arise. However, some patients eat and sleep more than usual; most of these patients will qualify for the atypical featuresspecifier.
Depressed patients will usually complain of fatigue, which they may express as tiredness or low energy. Their speech or physical movements may be slowed; sometimes there is a marked pause before answering a question or initiating an action. This is called psychomotor retardation. Speech may be very quiet, sometimes inaudible. Some patients simply stop talking completely, except in response to a direct question. At the extreme, complete muteness may occur.
At the other extreme, some depressed patients feel so anxious that they become agitated. Agitation may be expressed as hand wringing, pacing, or an inability to sit still. The ability of depressed patients to evaluate themselves objectively plummets; this shows up as low self-esteem or guilt. Some patients develop trouble with concentration (real or perceived) so severe that sometimes a misdiagnosis of dementia may be made. Thoughts of death, death wishes, and suicidal ideas are the most serious depressive symptoms of all, because there is a real risk that the patient will successfully act upon them.
To count as a DSM-5 symptom for major depressive episode, the behaviors listed above must occur nearly every day. However, thoughts about death or suicide need only be “recurrent.” A single suicide attempt or a specific suicide plan will also qualify.
In general, the more closely a patient resembles this outline, the more reliable will be the diagnosis of major depressive episode. We should note, however, that depressed patients can have many symptoms besides those listed in the DSM-5 criteria. They can include crying spells, phobias, obsessions, and compulsions. Patients may admit to feeling hopeless, helpless, or worthless. Anxiety symptoms, especially panic attacks, can be so prominent that they blind clinicians to the underlying depression.
Many patients drink more (occasionally, less) alcohol when they become depressed. This can lead to difficulty in sorting out the differential diagnosis: Which should be treated first, the depression or the drinking? (Hint: Usually, both at once.)
A small minority of patients lose contact with reality and develop delusions or hallucinations. These psychotic features can be either mood-congruent (for example, a depressed man feels so guilty that he imagines he has committed some awful sin) or mood-incongruent (a depressed person who imagines persecution by the FBI is not experiencing a typical theme of depression). Psychotic symptoms are indicated in the severity indicator (it’s verbiage you add to the diagnosis, and the final number in either the ICD-9 or ICD-10 code, as discussed later in this chapter). The case vignette of Brian Murphy includes an example.
There are three situations in which you should not count a symptom toward a diagnosis of major depressive episode:
1. A symptom is fully explained by another medical condition. For example, you wouldn’t count fatigue in a patient who is recovering from major surgery; in that situation, you expect fatigue.
2. A symptom results from mood-incongruent delusions or hallucinations. For example, don’t count insomnia that is a response to hallucinated voices that keep the patient awake throughout the night.
3. Feelings of guilt or worthlessness that occur because the patient is too depressed to fulfill responsibilities. Such feelings are too common in depression to carry any diagnostic weight. Rather, look for guilt feelings that are way outside the boundaries of what’s reasonable. An extreme example: A woman believes that her wickedness caused the tragedies of 9/11.
Impairment
The episode must be serious enough to cause material distress or to impair the patient’s work (or school) performance, social life (withdrawal or discord), or some other area of functioning, including sex. Of the various consequences of mental illness, the effect on work may the hardest to detect. Perhaps this is because earning a livelihood is so important that most people will go to great lengths to hide symptoms that could threaten their employment.
Exclusions
Regardless of the severity or duration of symptoms, major depressive episode usually should not be diagnosed in the face of clinically important substance use or a general medical disorder that could cause the symptoms.
Essential Features of Major Depressive Episode
These people are miserable. Most feel sad, down, depressed, or some equivalent; however, some few will instead insist that they’ve only lost interest in nearly all their once-loved activities. All will admit to varying numbers of other symptoms—such as fatigue, inability to concentrate, feeling worthless or guilty, and wishes for death or thoughts of suicide. In addition, three symptom areas may show either an increase or a decrease from normal: sleep, appetite/weight, and psychomotor activity. (For each of these, the classic picture is a decrease from normal—in appetite, for example—but some “atypical” patients will report an increase.)
The Fine Print
Also, children or adolescents may only feel or seem irritable, not depressed.
Don’t disregard the D’s: • Duration (most of nearly every day, 2+ weeks) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders)
Coding Notes
No code alert: Major depressive episode is not a diagnosable illness; it is a building block of major depressive, bipolar I, and bipolar II disorders. It may also be found in persistent depressive disorder (dysthymia). However, certain specifier codes apply to major depressive episodes—though you tack them on only after you’ve decided on the actual mood disorder diagnosis. Relax; this will all become clear as we proceed.
The bereavement exclusion that was used through DSM-IV is not to be found in DSM-5, because recent research has determined that depressions closely preceded by the death or loss of a loved one do not differ substantially from depressions preceded by other stressors (or possibly by none at all). There’s been a lot of breast beating over this move, or rather removal. Some claim that it places patients at risk for diagnosis of a mood disorder when context renders symptoms understandable; a substantial expansion in the number of people we regard as mentally ill could result.
I see the situation a little differently: We clinicians now have one fewer artificial barriers to diagnosis and treatment. However, as with any other freedom, we must use it responsibly. Evaluate the whole situation, especially the severity of symptoms, any previous history of mood disorder, the timing and severity of putative precipitant (bereavement plus other forms of loss), and the trajectory of the syndrome (is it getting worse or better?). And reevaluate frequently.
I’ve included examples of major depressive episode in the following vignettes: Brian Murphy, Elizabeth Jacks, Winona Fisk, Iris McMaster, Noah Sanders, Sal Camozzi, and Aileen Parmeter. In addition, there may be some examples in Chapter 20, “Patients and Diagnoses”—but you’ll have to find them for yourself.
Manic Episode
The second “building block” of the mood disorders, manic episode, has been recognized for at least 150 years. The classic triad of manic symptoms consists of heightened self-esteem, increased motor activity, and pressured speech. These symptoms are obvious and often outrageous, so manic episode is not often overdiagnosed. However, the psychotic symptoms that sometimes attend manic episode can be so florid that clinicians instead diagnose schizophrenia. This tendency to misdiagnosis may have decreased since 1980, when the DSM-III criteria increased clinicians’ awareness of bipolar illness. The introduction of lithium treatment for bipolar disorders in 1970 also helped promote the diagnosis.
Manic episode is much less common than major depressive episode, perhaps affecting 1% of all adults. Men and women are about equally likely to have mania.
The features that must be present in order to diagnose manic episode are identical to those for major depressive episode: (1) A mood quality that (2) has existed for a required period of time, (3) is attended by a required number of symptoms, (4) has resulted in a considerable degree of disability, and (5) violates none of the listed exclusions.
Quality of Mood
Some patients with relatively mild symptoms just feel jolly; this bumptious good humor can be quite infectious and may make others feel like laughing with them. But as mania worsens, this humor becomes less cheerful as it takes on a “driven,” unfunny quality that creates discomfort in patients and listeners alike. A few patients will have mood that is only irritable; euphoria and irritability sometimes occur together.
Duration
The patient must have had symptoms for a minimum of 1 week. This time requirement helps to differentiate manic episode from hypomanic episode.
Symptoms
In addition to the change in mood (euphoria or irritability), the patient must also have an increase in energy or activity level during a 1-week period. With these changes, at least three of the italicized symptoms listed below must also be present to an important degree during the same time period. (Note that if the patient’s abnormal mood is only irritable—that is, without any component of euphoria—four symptoms are required in addition to the increased activity level.)
Heightened self-esteem, found in most patients, can become grandiose to the point that it is delusional. Then patients believe that they can advise presidents and solve the problem of world hunger, in addition to more mundane tasks such as conducting psychotherapy and running the very medical facilities that currently house them. Because such delusions are in keeping with the euphoric mood, they are called mood-congruent.
Manic patients typically report feeling rested on little sleep. Time spent sleeping seems wasted; they prefer to pursue their many projects. In its milder forms, this heightened activity may be goal-directed and useful; patients who are only moderately ill can accomplish quite a lot in a 20-hour day. But as they become more and more active, agitation ensues, and they may begin many projects they never complete. At this point they have lost judgment for what is reasonable and attainable. They may become involved in risky business ventures, indiscreet sexual liaisons, and questionable religious or political activities.
Manic patients are eager to tell anyone who will listen about their ideas, plans, and work, and they do so in speech that is loud and difficult to interrupt. Manic speech is often rapid and pressured, as if there were too many dammed-up words trying to escape through a tiny nozzle. The resulting speech may exhibit what is called flight of ideas, in which one thought triggers another to which it bears only a marginally logical association. As a result, a patient may wander far afield from where the conversation (or monologue) started. Manic patients may also be easily distracted by irrelevant sounds or movements that other people would ignore.
Some manic patients retain insight and seek treatment, but many will deny that anything is wrong. They rationalize that no one who feels this well or is so productive could possibly be ill. Manic behavior therefore continues until it ends spontaneously or the patient is hospitalized or jailed. I consider manic episodes to be acute emergencies, and I don’t expect many clinicians will argue.
Some symptoms not specifically mentioned in the DSM-5 criteria are also worth noting here.
1. Even during an acute manic episode, many patients have brief periods of depression. These “microdepressions” are relatively common; depending on the symptoms associated with them, they may suggest that the specifier with mixed features is appropriate.
2. Patients may use substances (especially alcohol) in an attempt to relieve the uncomfortable, driven feeling that accompanies a severe manic episode. Less often, the substance use temporarily obscures the symptoms of the mood episode. When clinicians become confused about whether the substance use or the mania came first, the question can usually be sorted out with the help of informants.
3. Catatonic symptoms occasionally occur during a manic episode, sometimes causing the episode to resemble schizophrenia. But a history (obtained from informants) of acute onset and previous episodes with recovery can help clarify the diagnosis. Then the specifier with catatonic features may be indicated.
What about episodes that don’t start until the patient undergoes treatment for a depression? Should they count as fully as evidence of spontaneous mania or hypomania? To count as evidence for either manic or hypomanic episode, DSM-5 requires that the full criteria (not just a couple of symptoms, such as agitation or irritability) be present, and that the symptoms last longer than the expected physiological effects of the treatment. This declaration nicely rounds out the list of possibilities: DSM-IV stated flatly that manic episodes caused by treatment could not count toward a diagnosis of bipolar I disorder, whereas DSM-III-R implied that they could. And DSM-III kept silent on the whole matter.
The authors of the successive DSMs may have been thinking of Emerson’s famous epigram: A foolish consistency is the hobgoblin of little minds.
Impairment
Manic episodes typically wreak havoc on the lives of patients and their associates. Although increasing energy and effort may at first actually improve productivity at work (or school), as mania worsens a patient becomes less and less able to focus attention. Friendships are strained by arguments. Sexual entanglements can result in disease, divorce, and unwanted pregnancy. Even when the episode has resolved, guilt and recriminations remain behind.
Exclusions
The exclusions for manic episode are the same as for major depressive episode. General medical conditions such as hyperthyroidism can produce hyperactive behavior; patients who misuse certain psychoactive substances (especially amphetamines) will appear speeded up and may report feeling strong, powerful, and euphoric.
Essential Features of Manic Episode
Patients in the throes of mania are almost unmistakable. These people feel euphoric (though sometimes they’re only irritable), and there’s no way you can ignore their energy and frenetic activity. They are full of plans, few of which they carry through (they are so distractible). They talk and laugh, and talk some more, often very fast, often with flight of ideas. They sleep less than usual (“a waste of time, when there’s so much to do”), but feel great anyway. Grandiosity is sometimes so exaggerated that they become psychotic, believing that they are exalted personages (monarchs, rock stars) or that they have superhuman powers. With deteriorating judgment (they spend money unwisely, engage in ill-conceived sexual adventures), functioning becomes impaired, often to the point they must be hospitalized to force treatment or for their own protection or that of other people.
The Fine Print
The D’s: • Duration (most of nearly every day, 1+ weeks) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, schizoaffective disorder, neurocognitive disorders, hypomanic episodes, cyclothymia)
Coding Notes
Manic episode is not a diagnosable illness; it is a building block of bipolar I disorder.
Elisabeth Jacks had a manic episode; you can read her history beginning on page 131. Another example is that of Winona Fisk. Look for other cases in the patient histories given in Chapter 20.
Hypomanic Episode
Hypomanic episode is the final mood disorder “building block.” Comprising most of the same symptoms as manic episode, it is “manic episode writ small.” Left without treatment, some patients with hypomanic episode may become manic later on. But many, especially those who have bipolar II disorder, have repeated hypomanic episodes. Hypomanic episode isn’t codable as a diagnosis; it forms the basis for bipolar II disorder, and it can be encountered in bipolar I disorder, after the patient has already experienced an episode of actual mania. Hypomanic episode requires (1) a mood quality that (2) has existed for a required period of time, (3) is attended by a required number of symptoms, (4) has resulted in a considerable degree of disability, and (5) violates none of the listed exclusions. Table 3.1 compares the features of manic and hypomanic episodes.
TABLE 3.1 . Comparing Manic and Hypomanic Episodes
| Manic episode | Hypomanic episode | |
| Duration | 1 week or more | 4 days or more |
| Mood | Abnormally and persistently high, irritable, or expansive | |
| Activity/energy | Persistently increased | |
| Symptoms that are changes from usual behavior | Three or more a of grandiosity, ↓ need for sleep, ↑ talkativeness, flight of ideas or racing thoughts, distractibility (self-report or that of others), agitation or ↑ goal-directed activity, poor judgment | |
| Severity | Results in psychotic features, hospitalization, or impairment of work, social, or personal functioning | Clear change from usual functioning and Others notice this change and No psychosis, hospitalization, or impairment |
| Other | Rule out substance/medication-induced symptoms With mixed features if appropriate b |
a Four or more if the only abnormality of mood is irritability. b Both manic and hypomanic episodes can have the specifier with mixed features.
Quality of Mood
The quality of mood in hypomanic episode tends to be euphoric without the driven quality present in manic episode, though mood can instead be irritable. However described, it is clearly different from the patient’s usual nondepressed mood.
Duration
The patient must have had symptoms for a minimum of 4 days—a marginally shorter time requirement than that for manic episode.
Symptoms
As with manic episode, in addition to the change in mood (euphoria or irritability), the patient must also have an increase in energy or activity level—but again, only for 4 days. Then at least three symptoms from the same list must be present to an important degree (and represent a noticeable change) during this 4 days. If the patient’s abnormal mood is irritable and not elevated, four symptoms are required. Note that hypomanic episode precipitated by treatment can be adduced as evidence for, say, bipolar II disorder—if it persists longer than the expected physiological effects of the treatment.
The sleep of hypomanic patients may be brief, and activity level may be increased, sometimes to the point of agitation. Although the degree of agitation is less than in a manic episode, hypomanic patients can also feel driven and uncomfortable. Judgment deteriorates, and may lead to untoward consequences for finances or for work or social life. Speech may become rapid and pressured; racing thoughts or flight of ideas may be noticeable. Easily becoming distracted can be a feature of hypomanic episode. Heightened self-esteem is never so grandiose that it becomes delusional, and hypomanic patients are never psychotic.
In addition to the DSM-5 criteria, note that in hypomanic episode, as in manic episode, substance use is common.
Impairment
How severe can the impairment be without qualifying as a manic episode? This is to some extent a judgment call for the practitioner. Lapses of judgment, such as spending sprees and sexual indiscretions, can occur in both manic and hypomanic episodes—but, by definition, only the patient who is truly manic will be seriously impaired. If behavior becomes so extreme that hospitalization is needed or psychosis is evident, the patient can no longer be considered hypomanic, and the label must be changed.
Exclusions
The exclusions are the same as those for manic episode. General medical conditions such as hyperthyroidism can produce hyperactive behavior; patients who misuse certain substances (especially amphetamines) will appear speeded up and may also report feeling strong, powerful, and euphoric.
Essential Features of Hypomanic Episode
Hypomania is “mania lite”—many of the same symptoms, but never to the same outrageous degree. These people feel euphoric or irritable and they experience high energy or activity. They are full of plans, which, despite some distractibility, they sometimes actually implement. They talk a lot, reflecting their racing thoughts, and may have flight of ideas. Judgment (sex and spending) may be impaired, but not to the point of requiring hospitalization for their own protection or that of others. Though the patients are sometimes grandiose and self-important, these features never reach the point of delusion. You would notice the change in such a person, but it doesn’t impair functioning; indeed, sometimes these folks get quite a lot done!
The Fine Print
The D’s: • Duration (most of nearly every day, 4+ days) • Disability (work/educational, social, and personal functioning are not especially impaired) • Differential diagnosis (substance use and physical disorders, other bipolar disorders)
Coding Notes
Specify if: With mixed features.
There is no severity code.
Hypomanic episode is not a diagnosable illness; it is a building block of bipolar II disorder and bipolar I disorder.
MOOD DISORDERS BASED ON THE MOOD EPISODES
From this point, the format of my presentation differs somewhat from both that of the DSM-5 and that of the Quick Guide at the beginning of the chapter. First, I’ll discuss the mood disorders that use the mood episode “building blocks”—major depressive disorder and bipolar I and II disorders. Afterwards, I’ll cover the disorders that do not crucially involve these episodes.
Major Depressive Disorder
A patient who has one or more major depressive episodes, and no manic or hypomanic symptoms, is said to have major depressive disorder (MDD). It is a common condition, affecting about 7% of the general population, with a female preponderance of roughly 2:1. MDD usually begins in the middle to late 20s, but it can occur at any time of life, from childhood to old age. The onset may be sudden or gradual. Although episodes last on average from 6 to 9 months, the range is enormous, from a few weeks to many years. Recovery usually begins within a few months of onset, though that too can vary enormously. A full recovery is less likely for a person who has a personality disorder or symptoms that are more severe (especially psychotic features). MDD is strongly hereditary; first-degree relatives have a risk several times that of the general population.
Some patients have only a single episode during an entire lifetime; then they are diagnosed with (no surprise) MDD, single episode. However, roughly half the patients who have one major depressive episode will have another. At the point they develop a second episode (to count, it must be separated from the first by at least 2 months), we must change the diagnosis to MDD, recurrent type.
For any given patient, symptoms of depression remain pretty much the same from one episode to the next. These patients will have an episode roughly every 4 years; there is some evidence that the frequency of episodes increases with age. Multiple episodes of depression greatly increase the likelihood of suicide attempts and completed suicide. Unsurprisingly, patients with recurrent episodes are also much more likely than those with a single episode to be impaired by their symptoms. One of the most severe consequences is suicide, which is the fate of about 4% of patients with MDD.
Perhaps 25% of patients with MDD will eventually experience a manic or hypomanic episode, thereby requiring yet another change in diagnosis—this time to bipolar (I or II) disorder. We’ll talk more about them later.
Essential Features of Major Depressive Disorder, {Single Episode}{Recurrent}
The patient has {one}{or more} major depressive episodes and no spontaneous episodes of mania or hypomania.
The Fine Print
Two months or more without symptoms must intervene for episodes to be counted as separate.
Decide on the D’s: • Differential diagnosis (substance use and physical disorders, other mood disorders, ordinary grief and sadness, schizoaffective disorder)
Coding Notes
From type of episode and severity, find code numbers in Table 3.2. If applicable, choose specifiers from Table 3.3.
TABLE 3.2 . Coding for Bipolar I and Major Depressive Disorders
| Severity | Bipolar I, current or most recent episode a | Major depressive, current or most recent episode | |||
| Manic | Hypomanic | Depressed | Single | Recurrent | |
| Mild b | F31.11 [296.41] | F31.0 [296.40] (no severity, no psychosis for hypomanic episodes) | F31.31 [296.51] | F32.0 [296.21] | F33.0 [296.31] |
| Moderate c | F31.12 [296.42] | F31.32 [296.52] | F32.1 [296.22] | F33.1 [296.32] | |
| Severe d | F31.13 [296.43] | F31.4 [296.53] | F32.2 [296.23] | F33.2 [296.33] | |
| With psychotic features e | F31.2 [296.44] | — | F31.5 [296.54] | F32.3 [296.24] | F33.3 [296.34] |
| In partial remission f | F31.73 [296.45] | F31.71 [296.45] | F31.75 [296.55] | F32.4 [296.25] | F33.41 [296.35] |
| In full remission g | F31.74 [296.46] | F31.72 [296.46] | F31.76 [296.56] | F32.5 [296.26] | F33.42 [296.36] |
| Unspecified | F31.9 [296.40] | F31.9 [296.50] | F32.9 [296.20] | F33.9 [296.30] |
Note. Here are two examples of how you put it together: Bipolar I disorder, manic, severe with mood-congruent psychotic features, with peripartum onset, with mixed features. Major depressive disorder, recurrent, in partial remission, with seasonal pattern. Note the order: name → episode type → severity/psychotic/remission → other specifiers. Purchasers of this ebook can download a copy of this table from www.guilford.com/morrison2-forms. a If the bipolar I type isn’t specified, code as F31.9 [296.7]. b Mild. Meets the minimum of symptoms, which are distressing but interfere minimally with functionality. c Moderate. Intermediate between mild and severe. d Severe. Many serious symptoms that profoundly impede patient’s functioning. e If psychotic features are present, use these code numbers regardless of severity (it will almost always be severe, anyway). Record these features as mood-congruent or mood-incongruent. f Partial remission. Symptoms are no longer sufficient to meet criteria. g Full remission. For 2 months or more, the patient has been essentially free of symptoms.
TABLE 3.3 . Descriptors and Specifiers That Can Apply to Mood Disorders
Note. This table can help you to choose the sometimes lengthy string of names, codes, and modifiers for the mood disorders. Start reading from left to right in the table, putting in any modifiers that apply in the order you come to them. Dysthymia can also have early or late onset, plus a variety of additional specifiers. aThe catatonia specifier requires its own line of code and description. (See p. 100.) Purchasers of this ebook can download a copy of this table from www.guilford.com/morrison2-forms.
Brian Murphy
Brian Murphy had inherited a small business from his father and built it into a large one. When he sold out a few years later, he invested most of his money; with the rest, he bought a small almond farm in northern California. With his tractor, he handled most of the farm chores himself. Most years the farm earned a few hundred dollars, but as Brian was fond of pointing out, it really didn’t make much difference. If he never made a dime, he felt he got “full value from keeping busy and fit.”
When Brian was 55, his mood, which had always been normal, slid into depression. Farm chores seemed increasingly to be a burden; his tractor sat idle in its shed.
As his mood blackened, Brian’s body functioning seemed to deteriorate. Although he was constantly fatigued, often falling into bed by 9 P.M., he would invariably awaken at 2 or 3 A.M. Then obsessive worrying kept him awake until sunrise. Mornings were worst for him. The prospect of “another damn day to get through” seemed overwhelming. In the evenings he usually felt somewhat better, though he’d sit around working out sums on a magazine cover to see how much money they’d have if he “couldn’t work the farm” and they had to live on their savings. His appetite deserted him. Although he never weighed himself, he had to buckle his belt two notches smaller than he had several months before.
“Brian just seemed to lose interest,” his wife, Rachel, reported the day he was admitted to the hospital. “He doesn’t enjoy anything any more. He spends all his time sitting around and worrying about being in debt. We owe a few hundred dollars on our credit card, but we pay it off every month!”
During the previous week or two, Brian had begun to ruminate about his health. “At first it was his blood pressure,” Rachel said. “He’d ask me to take it several times a day. I still work part-time as a nurse. Several times he thought he was having a stroke. Then yesterday he became convinced that his heart was going to stop. He’d get up, feel his pulse, pace around the room, lie down, put his feet above his head, do everything he could to ‘keep it going.’ That’s when I decided to bring him here.”
“We’ll have to sell the farm.” That was the first thing Brian said to the mental health clinician when they met. Brian was casually dressed and rather rumpled. He had prominent worry lines on his forehead, and he kept feeling for his pulse. Several times during the interview, he seemed unable to sit still; he would get up from the bed where he was sitting and pace over to the window. His speech was slow but coherent. He talked mostly about his feelings of being poverty-stricken and his fears that the farm would have to go on the block. He denied having hallucinations, but admitted to feeling tired and “all washed up—not good for anything any more.” He was fully oriented, had a full fund of information, and scored a perfect 30 on the MMSE. He admitted that he was depressed, but he denied having thoughts about death. Somewhat reluctantly, he agreed that he might need treatment.
Rachel pointed out that with his generous disability policy, his investments, and his pension from his former company, they had more money coming in than when he was healthy.
“But still we have to sell the farm,” Brian replied.
Evaluation of Brian Murphy
Unfortunately, clinicians (including some mental health specialists) commonly make two sorts of mistakes when evaluating patients with depression.
First, we sometimes focus too intently on a patient’s anxiety, alcohol use, or psychotic symptoms and ignore underlying symptoms of depression or dysthymia. Here’s my lifelong rule, formulated from bitter experience (not all mine) as far back as when I was a resident: Always look for a mood disorder in any new patient, even if the chief complaint is something else.
Second, the presenting depressive or manic symptoms can be quite noticeable, even dramatic—to the point that clinicians may fail to notice, lurking underneath, the presence of alcohol use disorder or another disorder (good examples are neurocognitive and somatic symptom disorders). And that suggests another, equally important rule, almost the mirror image of the first rule: Never assume that a mood disorder is your patient’s only problem.
First, let’s try to identify the current (and any previous) mood episodes. Brian Murphy had been ill much longer than 2 weeks (criterion A). Of the major depressive episode symptoms listed (five are required by DSM-5), he had at least six: low mood (A1), loss of interest (A2), fatigue (A6), sleeplessness (A4), low self-esteem (A7), loss of appetite (A3), and agitation (A5). (Note that either low mood or loss of interest is required for diagnosis; Brian had both.) He was so seriously impaired (B) that he required hospitalization. Although we do not have the results of his physical exam and laboratory testing, the vignette provides no history that would suggest another medical condition (for example, pancreatic carcinoma) or substance use (C). However, his clinician would definitely need to ask both Brian and his wife about this—depressed people often increase their drinking. He was clearly severely depressed and different from his usual self. He easily fulfilled the criteria for major depressive episode.
Next, what type of mood disorder did Brian have? There had been no manic or hypomanic episodes (E), ruling out bipolar I or II disorder.His delusions of poverty could suggest a psychotic disorder (such as schizoaffective disorder), but he had too few psychotic symptoms, and the timing of mood symptoms versus delusions was wrong (D). He was deluded but had no additional A criteria for schizophrenia. His mood symptoms ruled out brief psychotic disorder and delusional disorder. He therefore fulfilled the requirements for MDD.
There are just two subtypes of MDD: single episode and recurrent. Although Brian Murphy might subsequently have other episodes of depression, this was the only one so far.
For the further description and coding of Brian Murphy’s depression, let’s turn to Table 3.2. His single episode dictates the column to highlight under MDD. And he was delusional, so we’d code him as with psychotic features.
But wait: Suppose he hadn’t been psychotic? What severity would we assign him then? Despite the fact that he wasn’t suicidal (he didn’t want death; rather, he feared it), he did have most of the required symptoms, and he was seriously impaired by his depressive illness. That’s why I’d rate him as severely depressed (but remember, the code number has already been determined).
Now we’ll turn to the panoply of other specifiers, which I’ll discuss toward the end of this chapter. Brian had no manic symptoms; that rules out with mixed features. His delusion that he was poor and would have to sell the farm was mood-congruent—that is, in keeping with the usual cognitive themes of depression. (However, the thought that his heart would stop and the pulse checking were probably not delusional. I’d regard them as signifying the overwhelming anxiety he felt about the state of his health.) The words we’d attach to his diagnosis (so far) would be MDD, single episode, severe with mood-congruent psychotic features.
But wait; there’s more. There were no abnormalities of movement suggestive of catatonic features, nor did his depression have any atypical features (for example, he didn’t have increased appetite or sleep too much). Of course, he would not qualify for peripartum onset. But his wife complained that he didn’t “enjoy anything any more,” suggesting that he might qualify for melancholic features. He was agitated when interviewed (marked psychomotor slowing would have also qualified for this criterion), and he had lost considerable weight. He reported awakening early on many mornings (terminal insomnia). The interviewer did not ask him whether this episode of depression differed qualitatively from how he felt when his parents died, but I’d bet that it did. So, we’ll add with melancholic features to the mix.
I wrote this vignette before a new specifier, with anxious distress, was a gleam in anyone’s eye, but I think Brian Murphy qualifies for it as well. He appeared edgy and tense, and he was markedly restless. Furthermore, he seemed to be expressing the fear that something horrible—possibly a catastrophic health event—would occur. Even though nothing was said about poor concentration, he had at least three of the symptoms required for the with anxious distress specifier, at a moderate severity rating. The evidence is that this specifier has real prognostic importance, suggesting, in the absence of treatment, the possibility of a poor outcome—even suicide.
Some patients with severe depression also report many of the symptoms typical of panic disorder, generalized anxiety disorder, or some other anxiety disorder. In such a case, two diagnoses could be made. Usually the mood disorder is listed first as the primary diagnosis. Anxiety symptoms that do not fulfill criteria for one of the disorders described in Chapter 4 may be further evaluated as evidence for the anxious distress specifier.
Of course, Brian wouldn’t qualify for rapid cycling or seasonal pattern; with only one episode, there could be no pattern. I’d give him a GAF score of 51, and his final diagnosis would be as given below.
Let me just say that the prospect of using so many different criteria sets to code one patient may seem daunting, but taking it one step at a time reveals a process that is really quite logical and (once you get the hang of it) fairly quick. The same basic methods should be applied to all examples of depression. (Of course, you could argue—I certainly would—that using the prototypical descriptions of depression and mania and their respective disorders simplifies things still further. But again, remember always to consider the possibility of substance use and physical causes of any given symptom set.)
| F32.3 [296.24] | Major depressive disorder, single episode, severe with mood-congruent psychotic features, with melancholic features, with moderate anxious distress |
There’s a situation in which I like to be extra careful about diagnosing MDD. That’s when a patient also has somatic symptom disorder. The problem is that many people who seem to have too many physical symptoms can also have mood symptoms that closely resemble major depressive episodes (and sometimes manic episodes). Over the years, I’ve found that these people tend to get treatment with medication, electroconvulsive therapy (ECT), and other physical therapies that don’t seem to help them much—certainly not for long. I’m not saying that drugs never work; I maintain only that if you encounter a patient with somatic symptom disorder who is depressed, other treatments (such as cognitive-behavioral therapy or other forms of behavior modification) may be more effective and less fraught with complications.
Aileen Parmeter
“I just know it was a terrible mistake to come here.” For the third time, Aileen Parmeter got out of her chair and walked to the window. A wiry 5 feet 2 inches, this former Marine master sergeant (she had supervised a steno pool) weighed a scant 100 pounds. Through the slats of the Venetian blinds, she peered longingly at freedom in the parking lot below. “I just don’t know whatever made me come.”
“You came because I asked you to,” her clinician explained. “Your nephew called and said you were getting depressed again. It’s just like last time.”
“No, I don’t think so. I was just upset,” she explained patiently. “I had a little cold for a few days and couldn’t play my tennis. I’ll be fine if I just get back to my little apartment.”
“Have you been hearing voices or seeing things this time?”
“Well, of course not.” She seemed rather offended. “You might as well ask if I’ve been drinking.”
After her last hospitalization, Aileen had been well for about 10 months. Although she had taken her medicine for only a few weeks, she had remained active until 3 weeks ago. Then she stopped seeing her friends and wouldn’t play tennis because she “just didn’t enjoy it.” She worried constantly about her health and had been unable to sleep. Although she didn’t complain of decreased appetite, she had lost about 10 pounds.
“Well, who wouldn’t have trouble? I’ve just been too tired to get my regular exercise.” She tried to smile, but it came off crooked and forced.
“Miss Parmeter, what about the suicidal thoughts?”
“I don’t know what you mean.”
“I mean, each time you’ve been here—last year, and 2 years before that—you were admitted because you tried to kill yourself.”
“I’m going to be fine now. Just let me go home.”
But her therapist, whose memory was long, had ordered Aileen held for her own protection in a private room where she could be observed one-on-one.
Sleepless still at 3 A.M., Aileen got up, smiled wanly at the attendant, and went in to use the bathroom. Looping a strip she had torn from her sweatsuit over the top of the door, she tried to hang herself. As the silence lengthened, the attendant called out softly, then tapped on the door, then opened it and sounded the alarm. The code team responded with no time to spare.
The following morning, the therapist was back at her bedside. “Why did you try to do that, Miss Parmeter?”
“I didn’t try to do anything. I must have been confused.” She gingerly touched the purple bruises that ringed her neck. “This sure hurts. I know I’d feel better if you’d just let me go home.”
Aileen remained hospitalized for 10 days. Once her sore neck would allow, she began to take her antidepressant medication again. Soon she was sleeping and eating normally, and she made a perfect score on the MMSE. She was released to go home to her apartment and her tennis, still uncertain why everyone had made such a fuss about her.
Evaluation of Aileen Parmeter
Aileen never acknowledged feeling depressed, but she had lost interest in her usual activities. This change had lasted longer than 2 weeks, and—as in previous episodes—her other symptoms included fatigue, insomnia, loss of weight, and suicidal behavior (criterion A). (Although she reproached herself for entering the hospital, these feelings referred exclusively to her being ill and would not be scored as guilt.) She was sick enough to require hospitalization, fulfilling the impairment criterion (B).
Aileen could have a mood disorder due to another medical condition, and this would have to be pursued by her clinician, but the history of recurrence makes this seem unlikely (C). Symptoms of apathy and poor memory raise the question of mild neurocognitive disorder, but her MMSE showed no evidence of memory impairment. She denied alcohol consumption, so a substance-induced mood disorder would also appear unlikely (her clinician had known her for so long that further pursuit of the possibility would be wasted effort).
There was no evidence that Aileen had ever had mania or hypomania, ruling out bipolar I or II disorder (E), and absence of any psychotic symptoms rules out psychotic disorders (D). She therefore fulfills the criteria for MDD. She’d had more than one episode separated by substantially longer than 2 months, which would satisfy the requirement for the term recurrent. Turning to Table 3.2, we can reject the rows there describing psychotic features (she emphatically denied having delusions or hallucinations) and remission.
Now we must consider the severity of her depression. It is always a problem how best to score someone with so little insight. Even with the suicide attempt, Aileen appeared barely to meet the five symptoms needed for major depressive episode. According to the rules, she should receive a severity coding of no greater than moderate. However, for a patient who has just nearly killed herself, this would be inaccurate and possibly dangerous; one of her symptoms, suicidal behavior, was very serious indeed. As I’ve said before, the coding instructions are meant to be guides, not shackles: I’d call Aileen’s depression severe.
She wouldn’t qualify for any of the specifiers for the most recent episode—perhaps because her lack of insight prevented her from providing full information. (I suppose that longer observation might reveal criteria adequate for with melancholic features.)
Other diagnoses are sometimes found in patients with MDD. These include several of the anxiety disorders, obsessive–compulsive disorder, and the substance-related disorders (especially alcohol use disorder). There is no evidence for any of these. I’d give her a GAF score of only 15 on admission. Her GAF had improved to 60 by the time she was released. Her complete diagnosis would be as follows:
| F33.2 [296.33] | Major depressive disorder, recurrent, severe |
Bipolar I Disorder
Bipolar I disorder is shorthand for any cyclic mood disorder that includes at least one manic episode. Although this nomenclature has only been adopted within the past several decades, bipolar I disorder has been recognized for over a century. Formerly, it was called manic–depressive illness; older clinicians may still refer to it this way. Men and women are about equally affected, for a total of approximately 1% of the general adult population. Bipolar I disorder is strongly hereditary.
There are two technical points to consider in evaluating episodes of bipolar I disorder. First, for an episode to count as a new one, it must either represent a change of polarity (for example, from major depressive to manic or hypomanic episode), or it must be separated from the previous episode by a normal mood that lasts at least 2 months.
Second, a manic or hypomanic episode will occasionally seem to be precipitated by the treatment of a depression. Antidepressant drugs, ECT, or bright light (used to treat seasonal depression) may cause a patient to move rapidly from depression into a full-blown manic episode. Bipolar I disorder is defined by the occurrence of spontaneous depressions, manias, and hypomanias; therefore, any treatment-induced manic or hypomanic episode can only be used to make the diagnosis of a bipolar I (or, for that matter, bipolar II) condition if the symptoms persist beyond the physiological effect of that treatment. Even then, DSM-5 urges caution: Demand the full number of manic or hypomanic symptoms, not just edginess or agitation that some patients experience following treatment of depression.
In addition, note the warning that the mood episodes must not be superimposed on a psychotic disorder—specifically schizophrenia, schizophreniform disorder, delusional disorder, or unspecified psychotic disorder. Because the longitudinal course of bipolar I disorder differs strikingly from those of the psychotic disorders, this should only rarely cause diagnostic problems.
Usually a manic episode will be current, and the patient will have been admitted to a hospital. Occasionally, you might use the category current or most recent episode manic for a newly diagnosed patient who is on a mood-stabilizing regimen. Most will have had at least one previous manic, major depressive, or hypomanic episode. However, a single manic episode is hardly rare, especially early in the course of bipolar I disorder. Of course, the vast majority of such patients will later have subsequent major depressive episodes, as well as additional manic ones. Males are more likely than females to have a first episode that is manic.
Current episode depressed (I’m intentionally shorthanding the long and unwieldy official phrase) will be one of the most frequently used of the bipolar I subtypes; nearly all patients with this disorder will receive this diagnosis at some point during their lifetimes. The depressive symptoms will be very much like those in the major depressive disorders of Brian Murphy and Aileen Parmeter. Elisabeth Jacks, whose current episode was manic, had been depressed a few weeks before her current evaluation.
In a given patient, symptoms of mood disorder tend to remain the same from one episode to the next. However, it is possible that after an earlier manic episode, a subsequent mood upswing may be less severe, and therefore only hypomanic. (The first episode of a bipolar I disorder couldn’t be hypomanic; otherwise, you’d have to diagnose bipolar II.) Although I have provided no vignette for bipolar I, most recent episode hypomanic, I have described a hypomanic episode in the case of Iris McMaster, a patient with bipolar II disorder.
Researchers who have followed bipolar patients for many years report that some have only manias. The concept of unipolar mania has been debated off and on for a long time. There are probably some patients who will never have a depression, but most will, given enough time. I have known of patients who had as many as seven episodes of mania over a 20-year period before finally having a first episode of depression. What’s important here is that all patients with bipolar I (and II) disorder—and their families—should be warned to watch out for depressive symptoms. Bipolar I patients have a high likelihood of completing suicide; some reports suggest that these people account for up to a quarter of all suicides.
Essential Features of Bipolar I Disorder
The patient has had at least one manic episode, plus any number (including zero) of hypomanic and major depressive episodes.
The Fine Print
A manic episode that was precipitated by treatment (medication, ECT, light therapy) can be counted toward a diagnosis of bipolar I disorder if the manic symptoms last beyond the expected physiological treatment effects.
The D’s: • Differential diagnosis (substance use and physical disorders, other bipolar disorders, psychotic disorder)
Coding Notes
From type of episode and severity, find code numbers in Table 3.2. Finally, choose from a whole lot of specifiers in Table 3.3.
Older patients who develop a mania for the first time may have a comorbid neurological disorder. They may also have a higher mortality. First-episode mania in the elderly may be quite a different illness from recurrent mania in the elderly, and should probably be given a different diagnosis, such as unspecified bipolar disorder.
Elisabeth Jacks
Elisabeth Jacks ran a catering service with her second husband, Donald, who was the main informant.
At age 38, Elisabeth already had two grown children, so Donald could understand why this pregnancy might have upset her. Even so, she had seemed unnaturally sad. From about her fourth month, she spent much of each day in bed, not arising until afternoon, when she began to feel a little less tired. Her appetite, voracious during her first trimester, fell off, so that by the time of delivery she was several pounds lighter than usual for a full-term pregnancy. She had to give up keeping the household and business accounts, because she couldn’t focus her attention long enough to add a column of figures. Still, the only time Donald became really alarmed was one evening at the beginning of Elisabeth’s ninth month, when she told him that she had been thinking for days that she wouldn’t survive childbirth and he would have to rear the baby without her. “You’ll both be better off without me, anyway,” she had said.
After their son was born, Elisabeth’s mood brightened almost at once. The crying spells and the hours of rumination disappeared; briefly, she seemed almost her normal self. Late one Friday night, however, when the baby was 3 weeks old, Donald returned from catering a banquet to find Elisabeth wearing only bra and panties and icing a cake. Two other just-iced cakes were lined up on the counter, and the kitchen was littered with dirty pots and pans.
“She said she’d made one for each of us, and she wanted to party,” Donald told the clinician. “I started to change the baby—he was howling in his basket—but she wanted to drag me off to the bedroom. She said ‘Please, sweetie, it’s been a long time.’ I mean, even if I hadn’t been dead tired, who could concentrate with the baby crying like that?”
All the next day, Elisabeth was out with girlfriends, leaving Donald home with the baby. On Sunday she spent nearly $300 for Christmas presents at an April garage sale. She seemed to have boundless energy, sleeping only 2 or 3 hours a night before arising, rested and ready to go. On Monday she decided to open a bakery; by telephone, she tried to charge over $1,600 worth of kitchen supplies to their Visa card. She’d have done the same the next day, but she talked so fast that the person she called couldn’t understand her. In frustration, she slammed the phone down.
Elisabeth’s behavior became so erratic that for the next two evenings Donald stayed off work to care for the baby, but his presence only seemed to provoke her sexual demands. Then there was the marijuana. Before Elisabeth became pregnant, she would have an occasional toke (she called it her “herbs”). During the past week, not all the smells in the house had been fresh-baked cake, so Donald thought she might be at it again.
Yesterday Elisabeth had shaken him awake at 5 A.M. and announced, “I am becoming God.” That was when he had made the appointment to bring her for an evaluation.
Elisabeth herself could hardly sit still during the interview. In a burst of speech, she described her renewed energy and plans for the bakery. She volunteered that she had never felt better in her life. In rapid succession she then described her mood (ecstatic), how it made her feel when she put on her best silk dress (sexy), where she had purchased the dress, how old she had been when she bought it, and to whom she was married at the time.
Patients who may have bipolar I disorder need a careful interview for symptoms of addiction to alcohol; alcohol use disorder is diagnosed as a comorbid disorder in as many as 30%. Often the alcohol-related symptoms appear first.
Evaluation of Elisabeth Jacks
This vignette provides a fairly typical picture of manic excitement. Elisabeth Jacks’s mood was definitely elevated. Aside from the issue of marijuana smoking (which appeared to be a symptom, not a cause), her relatively late age of onset was the only atypical feature.
For at least a week Elisabeth had had this high mood (manic episode criterion A), accompanied by most of the other typical symptoms (B): reduced need for sleep (B2), talkativeness (B3), flight of ideas (a sample run is given at the end of the vignette, B4), and poor judgment (buying Christmas gifts at the April garage sale—B7). Her disorder caused considerable distress, for her family if not for her (C); this is usual for patients with manic episode. The severity of the symptoms (not their number or type) and the degree of impairment were what would differentiate her full-blown manic episode from a hypomanic episode.
The issue of another medical condition (D) is not addressed in the vignette. Medical problems such as hyperthyroidism, multiple sclerosis, and brain tumors would have to be ruled out by the admitting clinician before a definitive diagnosis could be made. Delirium must be ruled out for any postpartum patient, but she was able to focus her attention well. Although Elisabeth may have been smoking marijuana, misuse of this substance should never be confused with mania; neither cannabis intoxication nor withdrawal presents the combination of symptoms typical of mania. Although the depression that occurred early in her pregnancy would have met the criteria for major depressive episode, her current manic episode would obviate major depressive disorder. Because the current episode was too severe for hypomanic symptoms, she could not have cyclothymic disorder. Therefore, the diagnosis would have to be bipolar I disorder (because she was hospitalized, it could not be bipolar II). The course of her illness was not compatible with any psychotic disorder other than brief psychotic disorder, and that diagnosis specifically excludes a bipolar disorder (B).
The bipolar I subtypes, as described earlier, are based upon the nature of the most recent episode. Elisabeth’s, of course, would be current episode manic.
Next we’ll score the severity of Elisabeth’s mania (see the footnotes to Table 3.2). These severity codes are satisfactorily self-explanatory, though there’s one problem: Whether Elisabeth was actually psychotic is not made clear in the vignette. If we take her words literally, she thought she was becoming God, in which case she would qualify for severe with psychotic features. These would be judged mood-congruent because grandiosity was in keeping with her exalted mood.
The only possible episode specifier (Table 3.3) would be with peripartum onset: She developed her manic episode within a few days of delivery. With a GAF score of 25, the full diagnosis would be as follows:
| F31.2 [296.44] | Bipolar I disorder, currently manic, severe with mood-congruent psychotic features, with peripartum onset |
Winona Fisk
By the time she was 21, Winona Fisk had already had two lengthy mental health hospitalizations, one each for mania and depression. Then she remained well for a year on maintenance lithium, which in the spring of her junior year in college she abruptly discontinued because she “felt so well.” When two of her brothers brought her to the hospital 10 days later, she had been suspended for repeatedly disrupting classes with her boisterous behavior.
On the ward, Winona’s behavior was mostly a picture of manic excitement. She spoke nonstop and was constantly on the move, often rummaging through other patients’ purses and lockers. But many of the thoughts flooding her mind were so sad that for 8 or 10 days she often spontaneously wept for several minutes at a time. She said she felt depressed and guilty—not for her behavior in class, but for being such a burden to her family. During these brief episodes, she claimed to hear the heart of her father beating from his grave, and she would express the wish to join him in death. She ate little and lost 15 pounds; she often awakened weeping at night and was unable to get back to sleep.
Nearly a month’s treatment with lithium, carbamazepine, and neuroleptics was largely futile. Her mood disorder eventually yielded to six sessions of bilateral ECT.
Evaluation of Winona Fisk
Winona’s two previous episodes of bipolar I disorder make that diagnosis crystal clear. Our only remaining task is to decide about the type and severity of the most recent episode.
In a typical manner, Winona’s manic episode began with feeling “too good” to be ill; that got her into trouble with her lithium. Her symptoms, which included poor judgment (she was suspended from class for her behavior), talkativeness, and increased psychomotor activity fulfilled criteria A and B for manic episode; hospitalization (C) ruled out hypomanic episode. (Her clinician would have to make sure she had no other medical or substance use disorder—criterion D.)
But at times throughout the day, she also had “microdepressions” during which she experienced at least three depressive symptoms, which would fulfill the criterion A requirements for the specifier with mixed features (manic episode): She felt depressed (A1), she expressed feelings of (inappropriate) guilt (A5), and she ruminated about death (A6). We cannot include her problems with sleep and appetite/weight; because they are found in both manic and depressive episodes, they don’t make the mixed features list. She didn’t meet full major depressive criteria, so there’s no need to fuss about whether to call her episode manic with mixed features, or major depressive with mixed features (C). And she didn’t drink or use drugs (D).
The severity of Winona’s episode should be judged on the basis of both the symptom count and the degree to which her illness affected her (and others). All things considered, her clinician felt that she was seriously ill, and coded her accordingly.
With a GAF score of 25, here’s Winona’s diagnosis:
| F31.2 [296.44] | Bipolar I disorder, current episode manic, severe with mood-congruent psychotic features, with mixed features |
| Z55.9 [V62.3] | Academic or educational problem (suspended from school) |
F31.81 [296.89] Bipolar II Disorder
The symptoms of bipolar II and bipolar I disorders have important similarities. The principal distinction, however, is the degree of disability and discomfort conferred by the high phase, which in bipolar II never involves psychosis and never requires hospitalization.* Bipolar II disorder consists of recurrent major depressive episodes interspersed with hypomanic episodes.
Like bipolar I disorder, bipolar II may be diagnosed on the basis of mood episodes that arise spontaneously or that are precipitated by antidepressants, ECT, or bright light therapy—if the induced symptoms subsequently last past the expected duration of the physiological treatment effects. (Be sure to ask the patient and informants whether there has been another hypomanic episode that was not precipitated by treatment; many patients will have had one.) Bipolar II is also associated with an especially high rate of rapid cycling, which carries added risk for a difficult course of illness.
Women may be more prone than men to develop bipolar II disorder (the sexes are about equally represented in bipolar I disorder); fewer than 1% of the general adult population are affected, though the prevalence among adolescents may be higher. The peripartum period may be especially likely to precipitate an episode of hypomania.
Comorbidity is a way of life for patients with bipolar II. Mostly they will have anxiety and substance use disorders, though eating disorders will also be in the mix, especially for female patients.
It is important to note that although I have earlier described hypomanic episode as “mania lite,” we shouldn’t imagine that the disorder is innocuous. Indeed, some studies suggest that patients with bipolar II are ill longer and spend more time in the depressive phase than is the case for patients with bipolar I. They may also be especially likely to make impulsive suicide attempts. And not a few (in the 10% range) will eventually experience a full-blown manic episode.
Sal Camozzi was another patient with bipolar II disorder; his history is given in Chapter 11.
Essential Features of Bipolar II Disorder
The patient has had at least one each of a major depressive episode and a hypomanic episode, but no manic episodes ever.
The Fine Print
The D’s: • Distress or disability (work/educational, social, or personal impairment, but only for depressive episodes or for switches between episodes) • Differential diagnosis (substance use and physical disorders, other bipolar disorders, major depressive disorder)
Coding Notes
Specify current or most recent episode as {hypomanic}{depressed}.
Choose any relevant specifiers, summarized in Table 3.3. For most recent episode, you can mention severity (free choice: mild, moderate, severe).
Iris McMaster
“I’m a writer,” said Iris McMaster. It was her first visit to the interviewer’s office, and she wanted to smoke. She fiddled with a cigarette but didn’t seem to know what to do with it. “It’s what I do for a living. I should be home doing it now—it’s my life. Maybe I’m the finest creative writer since Dostoevsky. But my friend Charlene said I should come in, so I’ve taken time away from working on my play and my comic novel, and here I am.” She finally put the cigarette back into the pack.
“Why did Charlene think you should come?”
“She thinks I’m high. Of course I’m high. I’m always high when I’m in my creative phase. Only she thinks I’m too nervous.” Iris was slender and of average height; she wore a bright pink spring outfit. She looked longingly at her pack of cigarettes. “God, I need one of those.”
Her speech could always be interrupted, but it was salted with bon mots, neat turns of phrase, and original similes. But Iris was also able to give a coherent history. At 45, she was married to an engineer and had a daughter who was nearly 18. And she really was a writer, who over the last several years had sold (mainly to women’s magazines) articles about a variety of subjects.
For 3 or 4 months Iris had been in one of her high phases, cranking out an enormous volume of essays on wide-ranging topics. Her “wired” feeling was uncomfortable in a way, but it hadn’t troubled her because she felt so productive. Whenever she was creating, she didn’t need much sleep. A 2-hour nap would leave her rested and ready for another 10 hours at her computer. At those times, her husband would fix his own meals and kid her about having “a one-track mind.”
Iris never ate much during her high phases, so she lost weight. But she didn’t get herself into trouble: no sexual indiscretions, no excessive spending (“I’m always too busy to shop”). And she volunteered that she had never “seen visions, heard voices, or had funny ideas about people following me around.” She had never spent time “in the funny farm.”
As Iris paused to gather her thoughts, her fingers clutched the cigarette package. She shook her head almost imperceptibly. Without uttering another word, she grabbed her purse, arose from the chair, and swooped out the door. It was the last the interviewer saw of her for a year and a half.
In November of the following year, a person announcing herself as Iris McMaster dropped into that same office chair. She seemed like an impostor. She’d gained 30 or 40 pounds, which she had stuffed into polyester slacks and a bulky knit sweater. “As I was saying,” were the first words she uttered. Just for a second, the corners of her mouth twitched up. But for the rest of the hour she soberly talked about her latest problem: writer’s block.
About a year ago, she had finished her play and was well into her comic novel when the muse deserted her. For months now, she had been arising around lunchtime and spending long afternoons staring at her computer. “Sometimes I don’t even turn it on!” she said. She couldn’t focus her thinking to create anything that seemed worth clicking on “save.” Most nights she tumbled into bed at 9. She felt tired and heavy, as though her legs were made of bricks.
“It’s cheesecake, actually,” was how Iris described her weight gain. “I have it delivered. For months I haven’t been interested enough to cook for myself.” She hadn’t been suicidal, but the only time she felt much better was when Charlene took her out to lunch. Then she ate and made conversation pretty much as she used to. “I’ve done that quite a lot recently, as anyone can see.” Once she returned home, the depression flooded back.
Finally, Iris apologized for walking out a year and a half earlier. “I didn’t think I was the least bit sick,” she said, “and all I really wanted to do was get back to my computer and get your character on paper!”
Evaluation of Iris McMaster
This discussion will focus on the episode of elevated mood Iris had during her first visit. There are two possibilities for such an episode: manic and hypomanic. As far as the time requirement was concerned, either type was possible—hypomanic requires 4 days (hypomanic episode criterion A), manic 1 week. She admitted that she felt “wired,” and this feeling had apparently been sustained for several months. It was also abnormal for her. During her high phase, she had at least four symptoms (three required, B): high self-esteem, decreased need for sleep, talkativeness, and increased goal-directed activity (writing).
The mood of either a manic or hypomanic episode is excessively high or irritable, and it is accompanied by increased energy and activity. The real distinction between hypomania and mania consists in the effects of the mood elevation on patient and surroundings. The patient’s functioning during a manic episode is markedly impaired, whereas in a hypomanic episode it is only a clear change from normal for the individual (C) that others can notice (D). During her high spells, Iris’s writing productivity actually increased, and her social relationships (those with her husband and friends, though perhaps not with her hapless clinician) did not appear to suffer (E). Note that the collective effect of criteria C, D, and E is to allow some impairment of functioning, just not very much.
Assuming that Iris had no other medical conditions or substance-induced mood disorder (F), she could have one of these three: bipolar I, bipolar II, or cyclothymic disorder. Judging from her lack of psychosis and hospitalizations, Iris had never had a true mania, ruling out bipolar I disorder. Her mood swings weren’t nearly numerous enough to qualify for a diagnosis of cyclothymic disorder.
That leaves bipolar II disorder. But to qualify for that diagnosis, there must be at least one major depressive episode (bipolar II criterion A). On Iris’s second visit to the clinician, her depressive symptoms included feeling depressed most of the time, weight gain, hypersomnia, fatigue, and poor concentration (her “writer’s block”), which fulfill the criterion A requirements for major depressive episode. If her depression had not met the criteria for major depressive episode, her diagnosis would have been unspecified (or other specified) bipolar disorder. That’s the same conclusion you’d reach for a patient who has never had a depression and only hypomanic episodes—or, for Iris McMaster, if she’d stayed the course for her first office visit.
In coding bipolar II disorder, clinicians are asked to specify the most recent episode. Iris’s was a depression. Although bipolar II disorder provides no severity code for a hypomanic episode, we can rate her depression by the same criteria we’d use for any other major depressive episode. Though she had only the minimum number of symptoms needed for major depressive episode, her work had been seriously impaired. For that reason, moderate severity seems appropriate, and is mirrored in her GAF score of 60. If further interview revealed additional (or more serious) symptoms, I’d consider boosting her to severe level. These specifiers leave leeway for the clinician’s judgment.
During her depression Iris had a number of symptoms of an episode specifier: with atypical features. That is, her mood seemed to brighten when she was having lunch with her friend; she also gained weight, slept excessively, and had a sensation of heaviness (bricks) in her limbs. With a total of four of these symptoms (only three are required), at the time of the second interview her full diagnosis would read as follows:
| F31.81 [296.89] | Bipolar II disorder, depressed, moderate, with atypical features |
ADDITIONAL MOOD DISORDERS
As we’ve discussed so far, many of the mood disorders seen in a mental health practice can be diagnosed by referring to manic, hypomanic, and major depressive episodes. These three mood episodes must be considered for any patient with mood symptoms. Next we’ll consider several other conditions that do not depend on these episodes for their definition.
F34.1 [300.4] Persistent Depressive Disorder (Dysthymia)
The condition discussed here goes by several names—dysthymic disorder, dysthymia, chronic depression, and now persistent depressive disorder. Whatever you call it (I’ll generally stick with dysthymia), these patients are indeed chronically depressed. For years at a time, they have many of the same symptoms found in major depressive episodes, including low mood, fatigue, hopelessness, trouble concentrating, and problems with appetite and sleep. But notice what’s absent from this list of symptoms (and from the criteria): inappropriate guilt feelings and thoughts of death or suicidal ideas. In short, most of these patients have an illness that’s enduring, but also relatively mild.
In the course of a lifetime, perhaps 6% of adults have dysthymia, with women about twice as often affected as men. Although it can begin at any age, late onset is uncommon, and the classic case starts so quietly and so early in life that some patients regard their habitual low mood as, well, normal. In the distant past, clinicians regarded these patients as having depressive personality or depressive neurosis.
Dysthymic patients suffer quietly, and their disability can be subtle: they tend to put much of their energy into work, with less left over for social aspects of life. Because they don’t appear severely disabled, such individuals may go without treatment until their symptoms worsen into a more readily diagnosed major depressive episode. This is the fate of many, probably most, dysthymic patients. In 1993 this phenomenon was recounted in a book that made The New York Times best-seller list: Listening to Prozac. However, the astonishing response to medication that book reported is by no means limited to one drug.
DSM-IV differentiated between dysthymic disorder and chronic major depressive disorder, but research has not borne out the distinction. So what DSM-5 now calls persistent depressive disorder is a combination of the two separate DSM-IV conditions. The current criteria supply some specifiers to indicate the difference. Here’s what’s clear: Patients who have depression that goes on and on (whatever we choose to call it) tend to respond poorly to treatment, are highly likely to have relatives with either bipolar disorders or some form of depression, and continue to be ill at follow-up.
There’s one other feature that results from the lumping together of dysthymia and chronic major depression. Because some major depression symptoms do not occur in the dysthymia criteria set, it is possible (as DSM-5 notes) that a few patients with chronic major depression won’t meet criteria for dysthymia: The combination of psychomotor slowing, suicidal ideas, and low mood/energy/interest would fit that picture (of those symptoms, only low energy appears among the B criteria for dysthymia). Improbable, I know, but there you are. We are advised that such patients should be given a diagnosis of major depressive disorder if their symptoms meet criteria during the current episode; if not, we’ll have to retreat to other specified (or unspecified) depressive disorder.
Essential Features of Persistent Depressive Disorder (Dysthymia)
“Low-grade depression” is how these symptoms are often described, and they occur most of the time for 2 years (they are never absent for longer than 2 months running). Some patients aren’t even aware that they are depressed, though others can see it. They will acknowledge such symptoms as fatigue, problems with concentration or decision making, poor self-image, and feeling hopeless. Sleep and appetite can be either increased or decreased. They may meet full requirements for a major depressive episode, but the concept of mania is foreign to them.
The Fine Print
For children, mood may be irritable rather than depressed, and the time requirement is 1 year rather than 2.
The D’s: • Duration (more days than not, 2+ years) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, ordinary grief and sadness, adjustment to a long-standing stressor, bipolar disorders, major depressive disorder)
Coding Notes
Specify severity.
Specify onset:
Early onset, if it begins by age 20.
Late onset, if it begins at age 21 or later.
Specify if:
With pure dysthymic syndrome. Hasn’t met full criteria for major depressive episode for the past 2 years.
With persistent major depressive episode. Does meet criteria throughout preceding 2 years.
With intermittent major depressive episodes, with current episode. Meets major depressive criteria now, but at times hasn’t.
With intermittent major depressive episodes, without current episode. Has met major depressive criteria in the past, though doesn’t currently.
Choose other specifiers from Table 3.3.
Noah Sanders
For Noah Sanders, life had never seemed much fun. He was 18 when he first noticed that most of the time he “just felt down.” Although he was bright and studied hard, throughout college he was often distracted by thoughts that he didn’t measure up to his classmates. He landed a job with a leading electronics firm, but turned down several promotions because he felt that he could not cope with added responsibility. It took dogged determination and long hours of work to compensate for this “inherent second-rateness.” The effort left him chronically tired. Even his marriage and the birth of his two daughters only relieved his gloom for a few weeks at a time, at best. His self-confidence was so low that, by common consent, his wife always made most of their family’s decisions.
“It’s the way I’ve always been. I am a professional pessimist,” Noah told his family doctor one day when he was in his early 30s. The doctor replied that he had a depressive personality.
For many years, that description seemed to fit. Then, when Noah was in his early 40s, his younger daughter left home for college; after this, he began to feel increasingly that life had passed him by. Over a period of several months, his depression deepened. He had worsened to the point that he now felt he had never really been depressed before. Even visits from his daughters, which had always cheered him up, failed to improve his outlook.
Usually a sound sleeper, Noah began awakening at about 4 A.M. and ruminating over his mistakes. His appetite fell off, and he lost weight. When for the third time in a week his wife found him weeping in their bedroom, he confessed that he had felt so guilty about his failures that he thought they’d all be better off without him. She decided that he needed treatment.
Noah was started on an antidepressant medication. Within 2 weeks, his mood had brightened and he was sleeping soundly; at 1 month, he had “never felt better” in his life. Whereas he had once avoided oral presentations at work, he began to look forward to them as “a chance to show what I could do.” His chronic fatigue faded, and he began jogging to use up some of his excess energy. In his spare time, he started his own small business to develop and promote some of his engineering innovations.
Noah remained on his medication thereafter. On the two or three occasions when he and his therapist tried to reduce it, he found himself relapsing into his old, depressive frame of mind. He continued to operate his small business as a sideline.
Evaluation of Noah Sanders
For most of his adult life, Noah’s mood symptoms were chronic, rather than acute or recurring. He was never without these symptoms for longer than a few weeks at a time (criterion C for dysthymia), and they were present most of the day, most days (A). They included general pessimism, poor self-image, and chronic tiredness, though only two symptoms are required by criterion B. His indecisiveness encouraged his wife to assume the role of family decision maker, which suggests social impairment (H). The way he felt was not different from his usual self; in fact, he said it was the way he had always been. (The extended duration is one of two main features that differentiate dysthymia from major depressive disorder. The other is that the required dysthymia symptoms are neither as plentiful nor as severe as for major depression.) Noah had had no manic or psychotic symptoms that might have us considering bipolar or psychotic disorders (E, F).
The differential diagnosis of dysthymia is essentially the same as that for major depressive disorder. Mood disorder due to another medical condition and substance-induced mood disorder must be ruled out (G). The remarkable chronicity and poor self-image invite speculation that Noah’s difficulties might be explained by a personality disorder, such as avoidant or dependent personality disorder. The vignette does not address all the criteria that would be necessary to make those diagnoses. However, an important diagnostic principle holds that the more treatable conditions should be diagnosed (and treated) first. If, despite relief of the mood disorder, Noah continued to be shy and awkward and to have a negative self-image, only then should we consider a personality diagnosis.
Now to the specifiers (Table 3.3). Though lacking psychotic symptoms, Noah had quite a number of depressive symptoms (including thoughts about death), which would suggest that he was severely ill. His dysthymia symptoms began when he was young (he first noticed them when he was just 18), so we’d say that his onset was early. Noah’s recent symptoms would also qualify for a major depressive episode, which had begun fairly recently and precipitated his evaluation; DSM-5 notes that a dysthymic patient can have symptoms that fulfill criteria for such an episode (D). We would therefore give him the specifier with intermittent major depressive episodes, with current episode. None of the course specifiers would apply to Noah’s dysthymia, but the following symptoms would meet the criteria for an episode specifier for the major depression—with melancholic features: He no longer reacted positively to pleasurable stimuli (being with his daughters); he described his mood as a definite change from normal; and he reported guilt feelings, early morning awakening, and loss of appetite.
Once treated, Noah seemed to undergo a personality change. His mood lightened and his behavior changed to the point that, by contrast, he seemed almost hypomanic. However, these symptoms don’t rise to the level required for a hypomanic episode; had that been the case, criterion E would exclude the diagnosis of dysthymia. (Also, remember that a hypomanic episode precipitated by treatment that does not extend past the physiological effects of treatment does not count toward a diagnosis of bipolar II disorder. It should not count against the diagnosis of dysthymia, either.) I thought his GAF score would be about 50 on first evaluation; his GAF would be a robust 90 at follow-up. In the summary, I’d note the possibility of avoidant personality traits.
My full diagnosis for Noah Sanders would be as follows:
| F34.1 [300.4] | Persistent mood disorder, severe, early onset, with intermittent major depressive episode, with current episode, with melancholic features (whew!) |
F34.0 [301.13] Cyclothymic Disorder
Patients with cyclothymic disorder (CD) are chronically either elated or depressed, but for the first couple of years, they do not fulfill criteria for a manic, hypomanic, or major depressive episode. Note that there’s a phrase back there dripping with italics. I’ll explain in the sidebar below.
Cyclothymic disorder was at one time regarded as a personality disorder. This may have been partly due to the fact that it begins so gradually and lasts such a long time. Articles in the literature still refer to cyclothymic temperament, which may be a precursor to bipolar disorders.
The clinical appearance can be very variable. Some patients are nearly always dysphoric, occasionally shifting into hypomania for a day or so. Others can shift several times in a single day. Often the presentation is mixed.
Typically beginning gradually in adolescence or young adulthood, CD affects under 1% of the general population. However, clinicians diagnose it even less often than you’d expect. The sex distribution is about equal, though women are more likely to come for treatment. Not surprisingly, patients usually only come to clinical attention when they are depressed. Once begun, it tends toward chronicity.
What if your cyclothymic patient later develops a manic, hypomanic, or major depressive episode? In that case, you’ll have to change the diagnosis to something different. Once a major mood episode rears its head, that patient can never revert to CD. If the new episode is major depressive, then you’ll probably fall back on an unspecified (or other specified) bipolar disorder, inasmuch as, by definition, the “up” periods of CD will not qualify as a hypomanic episode. Note that this is a change from DSM-IV, which allowed a diagnosis of a bipolar disorder along with CD.
Essential Features of Cyclothymic Disorder
The patient has had many ups and downs of mood that don’t meet criteria for any of the mood episodes (major depressive, hypomanic, manic). Although symptoms occur most of the time, as much as a couple of months of level mood can go by.
The Fine Print
The D’s: • Duration (2+ years; 1+ year in children and adolescents) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, other bipolar disorders)
Coding Notes
Specify if: With anxious distress.
Honey Bare
“I’m a yo-yo!”
Without her feathers and sequins, Honey Bare looked anything but provocative. She had begun life as Melissa Schwartz, but she loved using her stage name. The stage in question was Hoofer’s, one of the bump-and-grind joints that thrived near the waterfront. The billboard proclaimed that it was “Only a Heartthrob Away” from the Navy recruiting station. Since she’d dropped out of college 4 years earlier, Honey had been a front-liner in the four-girl show at Hoofer’s. Every afternoon on her way to work she passed right by the mental health clinic, but this was her first visit inside.
“In our current gig, I play the Statue of Liberty. I receive the tired, the poor, and the huddled masses. Then I take off my robes.”
“Is that a problem?” the interviewer wanted to know.
Most of the time, it wasn’t. Honey liked her little corner of show biz. When the fleet was in, she played to thunderous applause. “In fact, I enjoy just about everything I do. I don’t drink much, and I never do drugs, but I go to parties. I sing in our church choir, go to movies—I enjoy art films quite a bit.” When she felt well, she slept little, talked a lot, started a hundred projects, and even finished some of them. “I’m really a happy person—when I’m feeling up.”
But every couple of months, there’d be a week or two when Honey didn’t enjoy much of anything. She’d paste a smile on her face and go to work, but when the curtain rang down, the smile came off with her makeup. She was never suicidal, and her sleep and appetite didn’t suffer; her energy and concentration were normal. But it was as if all the fizz had gone out of her ginger ale. She could see no obvious cause for her mood swings, which had been going on for years. She could count on the fingers of both hands the number of weeks she had been “just normal.”
Lately, Honey had acquired a boyfriend—a chief petty officer who wanted to marry her. He said he loved her because she was so vivacious and enthusiastic, but he had only seen her when she was bubbly. Always before, when she was depressed, he had been out to sea. Now he had written that he was being transferred to shore duty, and she feared it would be the end of their relationship. As she said it, two large tears trickled through the mascara and down her cheeks.
Four months and several visits later, Honey was back, wearing a smile. The lithium carbonate, she reported, seemed to be working well. The peaks and valleys of her moods had smoothed out to rolling hills. She was still playing the Statue of Liberty down at Hoofer’s.
“My sailor’s been back for nearly 3 months,” she said, “and he’s still carrying the torch for me.”
As far back as the mid-19th century, Karl Kahlbaum—the German psychiatrist who first described catatonia—noted that some people experience frequent alterations between highs and lows so mild as not to require any treatment. His observations were confirmed and extended by his student and colleague, Ewald Hecker (who was best known for his description of hebephrenic schizophrenia).
But by the mid-20th century, the first DSM described cyclothymia as a cardinal personality type (along with schizoid, paranoid, and inadequate personalities). The description actually sounds pretty wonderful: “an extratensive and outgoing adjustment to life situations, an apparent personal warmth, friendliness and superficial generosity, an emotional reaching out to the environment, and a ready enthusiasm for competition.” (I’ll leave the looking-up of extratensive as an extra-credit exercise.) Anyway, thus was born cyclothymia as a temperament or personality style.
DSM-II kept cyclothymic personality with the other personality disorders, but in 1980 it was moved to the mood disorders and rechristened with its current name. However, its relationship to other mood disorders is fraught; experts argue about it even today. Many hold that it can be prodromal to a more severe bipolar disorder. Some point out the similarities between cyclothymia and borderline personality disorder (labile, irritable moods leading to interpersonal conflict), even suggesting that the latter disorder belongs on the bipolar spectrum—a speculation extreme enough to invite resistance.
All of this suggests that we still have work to do in determining cyclothymic disorder’s exact place in the diagnostic firmament. Though the DSM-5 criteria are a step along the road to differentiation of this venerable diagnosis, they may not signify any real progress.
Evaluation of Honey Bare
The first and most obvious question is this: Had Honey ever fulfilled criteria for a manic, hypomanic, or major depressive episode (cyclothymic disorder criterion C)? When feeling down, she had no vegetative symptoms (problems with sleep or appetite) of major depressive episode. She had normal concentration, had never been suicidal, and did not complain of feeling worthless. At the other pole, she did indeed have symptoms similar to those of hypomania (talkative, slept less, was more active than at other times), but they weren’t even severe enough for hypomania. Honey’s “up” moods weren’t elevated (or irritable, or expansive) to an abnormal extent (hypomanic episode criterion A)—they were her normal functioning. Furthermore, she had experienced far more cycles than would be typical for bipolar II disorder. We can therefore rule out any other bipolar or major depressive diagnosis.
Honey testified that she was either up or down most of the time (we’re back to cyclothymia—criterion B). Because she was never psychotic, she could not qualify for a diagnosis such as schizoaffective disorder (D). She didn’t use drugs or alcohol, ruling out a substance-induced mood disorder (E). Again, bipolar I, bipolar II, and major depressive disorders are ruled out due to the lack of relevant episodes. (However, because they involve so many swings of mood, either bipolar I or II with rapid cycling can sometimes be confused with cyclothymic disorder.) Mood shifts, impulsivity, and interpersonal problems can of course be found aplenty in borderline personality disorder, but we’d never diagnose a personality disorder when a major mental diagnosis was available.
Symptoms that were present much of the time would qualify Honey for CD. She had many mood swings; only infrequently was her mood neither high nor low. The only specifier allowed with CD, with anxious distress, didn’t to me seem relevant to Honey’s symptoms. With a GAF score of 70 on admission and 90 at follow-up, her diagnosis would be simple:
| F34.0 [301.13] | Cyclothymic disorder |
N94.3 [625.4] Premenstrual Dysphoric Disorder
A long history of disagreement over the reality of premenstrual dysphoria caused it to languish in the appendices of earlier DSM editions. At last, enough research has been published to bring it forth from the shadows.
Premenstrual symptoms to one degree or another affect about 20% of women of reproductive age. The severe form, premenstrual dysphoric disorder (PDD), affects up to 7% of women, often beginning in the teenage years. Throughout their reproductive years, these symptoms appear for perhaps a week out of each menstrual cycle. These women complain of varying degrees of dysphoric mood, fatigue, and physical symptoms that include sensitivity of breasts, weight gain, and abdominal swelling. Differentiation from major depressive episode and dysthymia relies principally on timing and duration.
The consequences of PDD can be serious: Such a patient could experience mood symptoms during an accumulated 8 years of her reproductive life. Some patients may be unaware how markedly their anger and other negative moods affect those around them, and many suffer from severe depression; perhaps 15% attempt suicide. Yet the typical patient doesn’t receive treatment until she is 30, sometimes even later. Symptoms may be worse for older women, though menopause offers a natural endpoint (duration is sometimes extended by hormone replacement therapy). Overall, this condition ranks high among the seriously underdiagnosed mental disorders.
Risk factors for PDD include excessive weight, stress, and trauma (including a history of abuse); there appears to be a robust genetic component. Comorbid are anxiety disorders and other mood disorders, including bipolar conditions.
Dating as far back as 1944—the term premenstrual tension dates at least to 1928—the premenstrual syndrome (PMS) has had a long and tempestuous life. It’s dismissed by many as pejorative, ridiculed by would-be comics, and disparaged even by some of those who practice gender politics. It should come as no surprise that it has been so ill received; as disorders go, PMS is remarkably vague and variously defined.
All told, PMS encompasses over a hundred possible symptoms, with no minimum number and no specific symptoms required; it’s all anecdotal. Here are just a few: fluid retention (the symptom most often reported), especially in breasts and abdomen; craving for sweet or salty foods; muscle aches/pains, fatigue, irritability, tension, acne, anxiety, constipation or diarrhea, and insomnia; a change in sex drive; and feeling sad or moody or out of control. Most women will occasionally have one or two of these symptoms around the time of their periods—these symptoms are so common that, individually, they may be considered physiological rather than pathological. This fact causes some people to blame all such symptoms on PMS (it hardly ever goes by its full, nonabbreviated name); all women are in effect tarred with the same brush, when it is of crucial importance to note the exact symptoms, their timing, and their intensity.
Again, the critical difference is the presence of mood symptoms in PDD.
Essential Features of Premenstrual Dysphoric Disorder
For a few days before menstruating, a patient experiences pronounced mood shifts, depression, anxiety, anger, or other expressions of dysphoria. She will also admit to typical symptoms of depression, including trouble concentrating, loss of interest, fatigue, feeling out of control, and changes in appetite or sleep. She may have physical symptoms such as sensitivity of breasts, muscle pain, weight gain, and a sensation of abdominal distention. Shortly after menstruation begins, she snaps back to normal.
The Fine Print
The D’s: • Duration (for several days around menstrual periods, for most cycles during the past year) • Distress or disability (social, occupational, or personal impairment) • Differential diagnosis (substance use—including hormone replacement therapy; physical disorders; major depressive disorder or dysthymia; ordinary grief/sadness)
Coding Note
DSM-5 says that the diagnosis can only be stated as (provisional) until you’ve obtained prospective ratings of two menstrual cycles. What you as a clinician decide to do with this is, of course, your business.
Amy Jernigan
“Look, I don’t need you to tell me what’s wrong. I know what’s wrong. I just need you to fix it.” One ankle crossed over the other, Amy Jernigan slouched in the consultation chair and gazed steadily at her clinician. “I brought a list of my symptoms, just so there won’t be any confusion.” She unfolded a half-sheet of embossed stationery.
“It always starts out 4 or 5 days before my period,” she recited. “I begin by feeling uptight, like I’m waiting to take an exam I haven’t studied for. Then, after a day or two, depression sets in and I just want to cry.” She looked up and smiled. “You won’t catch me doing that now—I’m always just fine after my period starts.”
Still in her early 20s, Amy had graduated from a college near her home in the Deep South. Now, while waiting for her novel to sell, she did research for a political blogger. With another glance at the paper, she continued. “But before, I’m depressed, cranky, lazy as a hound dog in August, and I don’t really give a shit about anything.”
Amy’s mother, an antifeminist who’d campaigned against the Equal Rights Amendment, had refused to validate Amy’s premenstrual symptoms, though she might have had them herself. Amy’s problems had begun in her early teens, almost from the time of her first period. “I’d be so pissed off, I’d drive away all my friends. Fortunately, I’m pretty outgoing, so they didn’t—don’t—stay lost for long. But reliably every month, my breasts get so sensitive they could read Braille. Then I know I’d better put a lock on my tongue, or the next week I’ll be buying beers for everyone I know.”
Amy tucked her list into her back pocket and sat up straight. “I hate being the feminist with PMS—I feel like a walking cliché.”
Discussion of Amy Jernigan
As Amy said, she didn’t need much discussion about what was wrong, though she didn’t have her terms quite right. Her list of symptoms—depression, irritability, and tension (criterion B) and breast tenderness, lethargy, and loss of interest (C)—exceeds the requirement for a total of five or more. Amy herself indicated just how debilitating she considered the symptoms to be (D). The recurrence, the timing, and the absence of symptoms at times other than before her menses (A) complete a pretty airtight case. The duration of her low moods was too brief for either a major depressive episode or dysthymia (E). Of course, the usual investigation must be made to rule out any lingering thoughts that her symptoms could be due to substance use or another medical condition (E). I should note that, in the absence of a couple of months of prospective symptom recording, Amy’s clinician needs to be extra careful to rule out major depressive disorder. It is awfully easy to ignore depressive symptoms that occur at other times of the month.
Amy’s clinician would have to assess her mood through two subsequent periods to comply with criterion F. When she was ill, her GAF score would be 60, and her diagnosis should be as follows:
| N94.3 [625.4] | Premenstrual dysphoric disorder (provisional) |
The demand for prospective data before a definitive diagnosis can be made is unique in DSM-5, and has never been required in a prior edition of the DSM. The rationale is to ensure that the diagnosis is made with the best data possible; the fact that such a step is not required for more diagnoses may be a nod to the realities of clinical practice. Even so, we may have just experienced the first breeze of a gathering storm.
F34.8 [296.99] Disruptive Mood Dysregulation Disorder
New in DSM-5, disruptive mood dysregulation disorder (DMDD) showcases extremes of childhood. Most kids fight among themselves, but DMDD broadens the scope and intensity of battle. Minor provocations (insufficient cheese in a sandwich, a favorite shirt in the wash) can provoke these children to fly completely off the handle. In a burst of temper, they may threaten or bully siblings (and parents). Some may refuse to comply with chores, homework, or even basic hygiene. These outbursts occur every couple of days on average, and between them, the child’s mood is persistently negative—depressed, angry, or irritable.
Their behavior places these children at enormous social, educational, and emotional disadvantage. Low assessments of functioning reflect the trouble they have interacting with peers, teachers, and relatives. They require constant attention from parents, and if they go to school at all, sometimes they need minders to ensure their own safety and that of others. Some suffer such intense rage that those about them actually fear for their lives. Even relatively mild symptoms may cause children to forgo many normal childhood experiences, such as play dates and party invitations. In one sample, a third had been hospitalized.
Perhaps as many as 80% of children with DMDD will also meet criteria for oppositional defiant disorder, in which case you would only diagnose DMDD. The diagnosis is more common in boys than in girls, placing it at odds with most other mood disorders, though right in line with most other childhood disorders. Although the official DSM-5 criteria remind us not to make the diagnosis prior to age 6, limited studies find that it is most common in preschool children. And it needs to be discriminated from teenage rebellion—the teens are a transitional period where mood symptoms are common.
The question has been asked: Why was DMDD not included in the same chapter with the disruptive, impulse-control, and conduct disorders? Of course, the original impetus was to give clinicians a mood-related alternative to bipolar I disorder. However, the prominent feature of persistently depressed (or irritable) behavior throughout the course of illness seems reason enough for placement with other mood disorders.
Partly because this diagnosis is intended for children, but mainly because I’m really worried about the validity of a newly concocted, poorly studied formulation (see the sidebar below), I’ll not provide a vignette or further discussion at this time. At the same time, I’m really, reallyworried about all those kids who are being lumbered with a diagnosis of bipolar disorder, with attendant drug treatment.
How many disorders can you name that originated in an uncomfortable bulge in the number of patients being diagnosed with something else? I can think of exactly one, and here is how it came about.
Beginning in the mid-1990s, a few prominent American psychiatrists sufficiently relaxed the criteria for bipolar disorder to allow that diagnosis in children whose irritability was chronic, not episodic. Subsequently, the number of childhood bipolar diagnoses ballooned. Many other experts howled at what they perceived to be a subversion of the bipolar criteria; thus were drawn the battle lines for diagnostic war.
In aggregate, a number of features seem to set these youngsters well apart from traditional patients with bipolar disorder: (1) Limited follow-up studies find some increase in depression, not mania, in these children as they mature. (2) Family history studies find no excess of bipolar disorder in relatives of these patients. (3) The sex ratio is about 2:1 in favor of boys, which is disparate with the 1:1 ratio for bipolar disorder in older patients. (4) Studies of pathophysiology suggest that brain mechanisms may differentiate the two conditions. (5) The diagnosis of childhood bipolar disorder has been made far more often in the United States than elsewhere in the world. (6) Follow-up studies find far more manic or hypomanic episodes in children with bipolar disorder diagnosed according to traditional criteria than in those whose principal issue was with severe mood dysregulation.
The epic internecine battle among American mental health professionals has been chronicled in a 2008 Frontline program (“The Bipolar Child”) on PBS and in a New York Times Magazine article by Jennifer Egan (“The Bipolar Puzzle,” September 12, 2008). The dispute continues; meanwhile, the DMDD category was crafted to capture more accurately the pathology of severely irritable children. The DSM-5 committee struggled to differentiate the two conditions, and I suspect that the struggles have only just begun.
Essential Features of Disruptive Mood Dysregulation Disorder
For at least a year, several times a week, on slight provocation a child has severe tantrums—screaming or actually attacking someone (or something)—that are inappropriate for the patient’s age and stage of development. Between outbursts, the child seems mostly angry, grumpy, or sad. The attacks and intervening moods occur across multiple settings (home, school, with friends). These patients have no manic episodes.
The Fine Print
Delve into the D’s: • Duration and demographics (1+ years, and never absent longer than 3 months, starting before age 10; the diagnosis can only be made from age 6 through 17) • Distress or disability (symptoms are severe in at least one setting—home, school, with other kids—and present in other settings) • Differential diagnosis (substance use and physical disorders, major depressive disorder, bipolar disorders, oppositional defiant disorder, attention-deficit/hyperactivity disorder, behavioral outbursts consistent with developmental age)
INDUCED MOOD DISORDERS
Substance/Medication-Induced Mood Disorders
Substance use is an especially common cause of mood disorder. Intoxication with cocaine or amphetamines can precipitate manic symptoms, and depression can result from withdrawal from cocaine, amphetamines, alcohol, or barbiturates. Note that for the diagnosis to be tenable, it must develop in close proximity to an episode of intoxication or withdrawal from the substance, which must in turn be capable of causing the symptoms.
Obviously, depression can occur with the misuse of alcohol and street drugs. (As DSM-5 notes, 40% or so of individuals with alcohol use disorder have depressive episodes, of which perhaps half are alcohol-induced, non-independent events.) However, even health care professionals can fail to recognize mood disorders caused by medications. That’s why the case of Erin Finn below is a cautionary tale, probably encountered every working day in clinicians’ offices around the world.
Essential Features of Substance/Medication-Induced Depressive Disorder
The use of some substance appears to have caused a patient to experience marked, persistent depressed mood or loss of interest in usual activities.
The Fine Print
For tips on identifying substance-related causation, see sidebar.
The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (physical disorders, other depressive disorders, “ordinary” substance intoxication or withdrawal, delirium)
Coding Notes
Specify if:
With onset during {intoxication}{withdrawal}. This gets tacked on at the end of your string of words.
With onset after medication use. You can use this in addition to other specifiers. See sidebar.
Code depending on whether there is evidence that supports a mild or moderate/severe substance use disorder (see Tables 15.2 and 15.3 in Chapter 15).
Essential Features of Substance/Medication-Induced Bipolar and Related Disorder
The use of some substance appears to have caused a mood that is euphoric or irritable.
The Fine Print
For tips on identifying substance-related causation, see sidebar.
The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (physical disorders, other bipolar disorders, schizoaffective disorder, “ordinary” substance intoxication or withdrawal, delirium)
Coding Notes
With onset during {intoxication}{withdrawal}. This gets tacked on at the end of your string of words.
With onset after medication use. You can use this in addition to other specifiers. See sidebar.
Code depending on whether there is evidence that supports a mild or moderate/severe substance use disorder (see Tables 15.2 and 15.3 in Chapter 15).
Erin Finn
Erin Finn came to the clinic straight from her job as media specialist at a political campaign. She’d taken part in her state’s screening program for hepatitis C, which targeted people in her age group—reared before routine testing of the blood supply had reduced the incidence of the disease. Her test had come back positive. When the RNA polymerase test revealed a viral load, she’d agreed to a trial of interferon. “I sometimes feel tired, but I’ve had no other symptoms,” she’d told her doctor.
Though solidly middle-class and conservatively dressed, Erin had actually had a number of possible exposures to hepatitis C. The most likely was a years-ago blood transfusion, but she’d also “had a wild-ish youth, experimented with injectable drugs a few times, even got a tattoo. It’s more or less discreet—the tattoo, I mean.”
Within a few days of starting the medication, she’d begun to complain of feeling depressed, first mildly, then increasing day by day. “It felt worse than that day last year when we thought we’d lost in the primary election,” she told the interviewer. “It’s been a horrible combination of sleeping poorly at night and never completely waking up during the day. And feeling draggy, and tired, and . . . ” She groped for words while fiddling with the two campaign buttons pinned to her coat.
Originally hired to do data entry, Erin had been promoted to write campaign materials for brochures and television. But because she was depressed most of the day, her inability to concentrate had resulted in mistakes. “I’m a crap worker,” she said, “always making simple mistakes in grammar and spelling. It’ll be my fault if we lose in November.”
After a moment, she added, “But I’m not suicidal, I’m not that dumb. Or desperate. But some days, I just wish I was dead.” She thought for a moment. “Were dead!” she corrected herself. “And my boyfriend tells me I’m useless in bed. Along with everything else, I just don’t seem to care about that any more, either.”
Erin subsequently stopped the interferon, and her mood and other symptoms gradually returned to normal. “So the doctor thought I ought to try the interferon again, as a sort of challenge. At first, I said that was a total nonstarter! But then I got to worrying some more about cirrhosis, and thought I’d give it another shot. So to speak.”
She shrugged as she rolled up her sleeve. “I guess hepatitis treatment has a lot in common with politics—neither of them’s bean-bag.”
Evaluation of Erin Finn
Erin’s symptoms would rate her a diagnosis of (relatively mild) major depressive episode, even leaving out the fatigue (which we won’t count because it antedated her use of interferon). Even without all those depressive symptoms, the mere fact of having such a pronounced low mood would fulfill the requirement for medication-induced depressive disorder criterion A. The timing was right (B1), and interferon is well known to produce depressive symptoms in a sizeable number of patients (though more often in those who have had previous mood episodes—B2). And, although it was hardly a controlled experiment, her depressive symptoms did clear up right away, once she stopped the interferon. DSM-5 doesn’t specify a challenge test (sometimes such a test is inadvisable), but a return of Erin’s depressive symptoms after she resumed the medication would forge the final cause-and-effect link.
OK, so we should consider other possible causes of her depression (criteria C and D). I’ll leave that as an exercise for the reader. As for criterion E (distress and disability), res ipsa loquitur. When we turn to Table 15.2 in Chapter 15 for ICD-10 coding, her substance was “Other” (F19), and she had obviously used it only as prescribed, so there was no use disorder. Cross-indexing with the mood disorder column yields F19.94. The ICD-9 code comes from Table 15.3. I would give her GAF score as 55 on admission, 90 at discharge.
| F19.94 [292.84] | Interferon-induced depressive disorder, with onset after medication use |
| B18.2 [070.54] | Chronic hepatitis C |
Mood Disorders Due to Another Medical Condition
Many medical conditions can cause depressive or bipolar symptoms, and it is vital always to consider physical etiologies when evaluating a mood disorder. This is not only because they are treatable; with today’s therapeutic options, most mood disorders are highly treatable. It is because some of the general medical conditions, if left inadequately treated too long, themselves have serious consequences—including death. And there are not a few that can cause manic symptoms. I’ve mentioned some of these in the “Physical Disorders That Affect Mental Diagnosis” table in the Appendix, though that table is by no means comprehensive.
Note this really important requirement: The medical condition has to have been the direct, physiological cause of the bipolar or depressive symptoms. Psychological causation (for instance, the patient feels understandably terrible upon being told “it’s cancer”) doesn’t count, except as the possible precipitant for an adjustment disorder.
The vignette of Lisa Voorhees below illustrates the importance of keeping in mind that medical conditions can cause mood disorders.
Essential Features of Depressive Disorder Due to Another Medical Condition
A physical medical condition appears to have caused a patient to experience a markedly depressed mood or loss of interest or pleasure in most activities.
The Fine Print
For pointers on deciding when a physical condition may have caused a mental disorder, see sidebar.
The D’s: • Duration (none stated, though it would not be fleeting) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use disorders, other depressive disorders, delirium)
Coding Notes
Specify:
F06.31 [293.83] With depressive features. You cannot identify full symptomatic criteria for a major depressive episode.
F06.32 [293.83] With major depressive-like episode. You can.
F06.34 [293.83] With mixed features. Manic or hypomanic symptoms are evident but not predominant over the depressive symptoms.
It is only with DSM-5 that criteria have been written specifically differentiating medically induced bipolar from medically induced depressive disorders. What if you can’t tell? Some mood disorders, in their early stages, may be too indistinct to call. You might then be reduced to diagnosing mood disorder due to a medical condition (F06.30) or substance-induced mood disorder (F19.94).
Essential Features of Bipolar and Related Disorder Due to Another Medical Condition
A physical medical condition appears to have caused a patient to experience both an elevated (or irritable) mood and an atypical increase in energy or activity, though full manic episode symptoms may not be present.
The Fine Print
For pointers on deciding when a physical condition may have caused a mental disorder, see sidebar.
The D’s: • Duration (none stated, though it would not be fleeting) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use disorders, other bipolar disorders, other mental disorders, delirium)
Coding Notes
Specify:
F06.33 [293.83] With manic- or hypomanic-like episode. You can identify full symptomatic criteria for mania or hypomania.
F06.33 [293.83] With manic features. Full mania or hypomania criteria are not met.
F06.34 [293.83] With mixed features. Depressive symptoms are evident but not predominant over the manic symptoms.
Lisa Voorhees
By the time she arrived at the mental health clinic, Lisa Voorhees had already seen three doctors. Each of them had thought that her problems were entirely mental. Although she had “been 39 for several years,” she was slender and smart, and she knew that she was attractive to men.
She intended to stay that way. Her job as personal secretary to the chairman of the department of English and literature at a large Midwestern university introduced her to a lot of eligible males. And that was where Lisa first noticed the problem that made her think she was losing her mind.
“It was this gorgeous assistant professor of Romance languages,” she told the interviewer. “He was always in and out of the office, and I’d done everything short of sexual harassment to get him to notice me. Then one day last spring, he asked me out to dinner and a show. And I turned him down! I just wasn’t interested. It was as if my sex drive had gone on sabbatical!”
For several weeks she continued to feel uninterested in men, and then one morning she “woke up next to some odious creep from the provost’s office” she’d been avoiding for months. She felt disgusted with herself, but they had sex again anyway, before she kicked him out.
For the next several months, Lisa’s sexual appetite would suddenly change every 2 or 3 weeks. Privately, she had begun to call it “The Turn of the Screw.” During her active phase, she felt airy and light, and could pound away on her computer 12 hours a day. But the rest of the time, nothing pleased her. She was depressed and grouchy at the office, slept badly (and alone), and joked that her keyboard and mouse were conspiring to make her feel clumsy.
Even Lisa’s wrists felt weak. She had bought a wrist rest to use when she was typing, and that helped for a while. But she could find neither splint nor tonic for the fluctuations of her sex drive. One doctor told her it was “the change” and prescribed estrogen; another diagnosed “manic–depression” and offered lithium. A third suggested pastoral counseling, but instead she had come to the clinic.
In frustration, Lisa arose from her chair and paced to the window and back.
“Wait a minute—do that again,” the interviewer ordered.
“Do what? All I did was walk across the room.”
“I know. How long have you had that limp?”
“I don’t know. Not long, I guess. What with the other problems, I hardly noticed. Does it matter?”
It proved to be the key. Three visits to a neurologist, some X-rays, and an MRI later, Lisa’s diagnosis was multiple sclerosis. The neurologist explained that multiple sclerosis sometimes caused mood swings; treatment for it was instituted, and Lisa was referred back to the mental health clinic for psychotherapy.
Evaluation of Lisa Voorhees
On paper, the various criteria sets make reasonably clear-cut the differences between mood disorders with “emotional” causes and those caused by general medical conditions or substance use. In practice, it isn’t always obvious.
Lisa’s mood symptoms alternated between periods of highs and lows. Although they lasted 2 weeks or longer, none of these extremes was severe enough to qualify as a manic, hypomanic, or major depressive episode. The depressed period was too brief for dysthymia; the whole episode had not lasted long enough for cyclothymic disorder; and there was no evidence of a substance-induced mood disorder.
Depressive (or bipolar) disorder due to another medical condition must fulfill two important criteria. The first is that symptoms must be directly produced by physiological mechanisms of the illness itself, not simply by an emotional reaction to having the illness. For example, patients with cancer of the head of the pancreas are known to have a special risk of depression, which doesn’t occur just as a reaction to the news or continuing stress of having a serious medical problem.
Several lines of evidence could bear on a causal relationship between a medical condition and mood symptoms. A connection may exist if the mood disorder is more severe than the general medical symptoms seem to warrant or than the psychological impact would be on most people. However, such a connection would not be presumed if the mood symptoms begin before the patient learns of the general medical condition. Similar mood symptoms developing upon the disclosure of a different medical problem would argue against a diagnosis of either bipolar or depressive disorder due to another medical condition. By contrast, arguing for a connection would be clinical features different from those usual for a primary mood disorder (such as atypical age of onset). None of these conditions obtained in the case of Lisa Voorhees.
A known pathological mechanism that can explain the development of the mood symptoms in physiological terms obviously argues strongly in favor of a causal relationship. Multiple sclerosis, affecting many areas of the brain, would appear to satisfy this criterion. A high percentage of patients with multiple sclerosis have reported mood swings. Periods of euphoria have also been reported in these patients; anxiety may be more common still.
Many other medical conditions can cause depression. Endocrine disorders are important causes: Hypothyroidism and hypoadrenocorticalism are associated with depressive symptoms, whereas hyperthyroidism and hyperadrenocorticalism are linked with manic or hypomanic symptoms. Infectious diseases can cause depressive symptoms (many otherwise normal people have noted lassitude and low mood when suffering from a bout of the flu; Lyme disease has been getting a lot of attention recently). Space-occupying lesions of the brain (tumors and abscesses) have also been associated with depressive symptoms, as have vitamin deficiencies. Finally, about one-third of patients with Alzheimer’s disease, Huntington’s disease, and stroke may develop serious depressive symptoms.
The second major criterion for a mood disorder due to another medical condition is that the mood symptoms must not occur only during the course of a delirium. Delirious patients can have difficulties with memory, concentration, lack of interest, episodes of tearfulness, and frank depression that closely resemble major depressive disorder. Lisa presented no evidence that suggested delirium.
As to the specifier, we could choose between with manic features and with mixed features (see Essential Features, above). At different times, Lisa had both extremes of mood; neither predominated, so I’d go with . . . well, see below, along with a GAF score of 70. The code and name of the general medical condition would be included, as follows, with the name of the medical condition:
| F06.34 [293.83] | Bipolar disorder due to multiple sclerosis, with mixed features |
| G35 [340] | Multiple sclerosis |
MODIFIERS OF MOOD DIAGNOSES
Table 3.3 shows at a glance when and how to apply each of the modifiers of mood disorders covered below.
Severity and Remission
Severity Codes
Neither major depressive episode, manic episode, nor hypomanic episode is codable (stop me if you’ve heard this before). Instead, we use each as the basis for other diagnoses. However, they do have severity codes attached to them, and the same severity codes are used for major depressive and manic episodes. Use these codes for the current or most recent major depressive episode in major depressive, bipolar I, or bipolar II disorders, or the current or most recent manic episode in the two bipolar disorders. (Hypomanic episode is by definition relatively mild, so it gets no severity specifier.)
The basic severity codes for manic and major depressive episodes are these:
Mild. Symptoms barely fulfill the criteria and result in little distress or interference with the patient’s ability to work, study, or socialize.
Moderate. Intermediate between mild and severe.
Severe. There are several symptoms more than the minimum for diagnosis, and they markedly interfere with patient’s work, social, or personal functioning.
Remission Codes
The majority of patients with bipolar disorders recover completely between episodes (and most of them will have subsequent episodes). Still, up to a third of patients with bipolar I do not recover completely. The figures for patients with major depressive disorder are not quite so grim. Following are two specifiers for current status of both these disorders, as well as bipolar II disorder and persistent depressive disorder (aka dysthymia).
In partial remission. A patient who formerly met full criteria and now either (1) has fewer than the required number of symptoms or (2) has had no symptoms at all, but for under 2 months.
In full remission. For at least 2 months, the patient has had no important symptoms of the mood episode.
Specifiers That Describe the Most Recent Mood Episode
The episode specifiers describe features of the patient’s current or most recent episode of illness. No additional code number is assigned for these features; you just write out the verbiage. Again, Table 3.3 shows at a glance when you can use each of the following special qualifiers.
With Anxious Distress
Patients with bipolar I, bipolar II, cyclothymic, major depressive, or persistent depressive disorder may experience symptoms of high anxiety. These patients may have a greater than average potential for suicide and for chronicity of illness.
Essential Features of With Anxious Distress
During a major depressive/manic/hypomanic episode or dysthymia, the patient feels notably edgy or tense, and may be extra restless. Typically, it is hard to focus attention because of worries—“Something terrible could happen,” or “I could lose control and [fill in the awful consequence] . . . ”
Coding Notes
Specify severity: mild (2 symptoms of anxious distress), moderate (3 symptoms), moderate–severe (4–5 symptoms), severe (4–5 symptoms plus physical agitation)
See Table 3.3 for application.
There’s something kind of funny here. We’ve been given a mood specifier that has its own severity scale, derived (as are manic and major depressive episodes) by counting symptoms. If there’s any other place in DSM-5 where it’s possible to have two separate severity ratings in the same diagnosis, I don’t recall it. (Other specifiers have several symptoms to count; for example, why don’t we also rate severity of with melancholic features?) Furthermore, it is at least theoretically possible for a patient to have mild depression with severe anxious distress. Of course, you can rate each part independently, but it could be confusing and it sounds a little silly. My approach would be to focus on the severity of the mood episode. The specifier will probably get along just fine on its own.
With Atypical Features
Not all seriously depressed patients have the classic vegetative symptoms typical of melancholia (see below). Patients who have atypical features seem almost the reverse: Instead of sleeping and eating too little, they sleep and eat too much. This pattern is especially common among younger (teenage and college-age) patients. Indeed, it is common enough that it might better be called nonclassic depression.
Two reasons make it important to specify with atypical features. First, because such patients’ symptoms often include anxiety and sensitivity to rejection, they risk being mislabeled as having an anxiety disorder or a personality disorder. Second, they may respond differently to treatment than do patients with melancholic features. Atypical patients may respond to specific antidepressants (monoamine oxidase inhibitors), and may also show a favorable response to bright light therapy for seasonal (winter) depression.
Iris McMaster’s bipolar II disorder included atypical features.
Essential Features of With Atypical Features
A patient experiencing a major depressive episode feels better when something good happens (“mood reactivity,” which obtains whether the patient is depressed or well). The patient also has other atypical symptoms: an increase in appetite or weight (the classic depressed patient reports a decrease), excessive sleeping (as opposed to insomnia), a feeling of being sluggish or paralyzed, and long-existing (not just when depressed) sensitivity to rejection.
The Fine Print
The with atypical features specifier cannot be used if your patient also has melancholia or catatonic features. See Table 3.3 for application.
With Catatonia
The catatonia specifier, first mentioned in Chapter 2 in association with the psychotic disorders, can be applied to manic and major depressive (but not hypomanic) episodes of mood disorders as well. The definitions of the various terms are given in the sidebar. When you use it, you have to add a line of extra code after listing and coding the other mental disorder:
| F06.1 [293.89] | Catatonia associated with [state the mental disorder] |
I’ve given an example in the case of Edward Clapham.
With Melancholic Features
The with melancholic features specifier refers to the classical “vegetative” symptoms of severe depression and a negative view of the world. Melancholic patients awaken too early in the morning, feeling worse than they do later in the day. They also have reduced appetite and lose weight. They take little pleasure in their usual activities (including sex) and are not cheered by the presence of people whose company they normally enjoy. This loss of pleasure is not merely relative, but total or nearly so. Brian Murphy is an example of such a patient; Noah Sanders is another.
Melancholic features are especially common among patients who first develop severe depression in midlife. This condition used to be called involutional melancholia, from the observation that it seemed to occur in patients who were in middle to old age (life’s so-called “involutional” period). However, it is now recognized that melancholic features can affect patients of any age; they are especially likely to occur in psychotic depressions. Depression with melancholia usually responds well to somatic treatments such as antidepressant medication and ECT. Contrast this picture with that given for with atypical features (see above).
Again, see Table 3.3 for details of when to apply this specifier.
Essential Features of With Melancholic Features
In the depths of a major depressive episode, the patient cannot find pleasure in accustomed activities or feels no better if something good happens (OK, could be both). Such a patient also experiences some of these: a mood more deeply depressed than what you’d expect during bereavement; diurnal variation of mood (more depressed in the morning); terminal insomnia (awakening at least 2 hours early); change in psychomotor activity (sometimes agitated, more often slowed down); marked loss of appetite or weight; and guilt feelings that are unwarranted or excessive. This form of depression is extremely severe and can border on psychosis.
Coding Notes
You can apply this specifier to a major depressive episode, wherever it occurs: major depressive disorder (single episode or recurrent), bipolar I or II disorder, or persistent depressive disorder. See Table 3.3.
With Mixed Features
In 1921, Emil Kraepelin first described mixed forms of mania and depression. DSM-IV and its predecessors included a mixed episode among the mood disorders. Now that it’s been retired, DSM-5 offers a with mixed features specifier to use with patients who within the same time frame have symptoms of depression and mania (or hypomania). The features of the two opposite poles occur more or less at the same time, though some patients experience the gradual introduction (then fading away) of, say, depression into a manic episode.
However, researchers are only just ascertaining the degree to which such a patient differs from someone with “pure” episodic mania or depression. Patients who have mixed features appear to have more total episodes and more depressive episodes, and remain ill longer. They may tend to have more comorbid mental illness and greater suicide risk. Their work is more likely to be impaired. Patients with major depressive disorder who have mixed features are especially likely to develop a bipolar disorder in the future.
Despite this attention, we’ll probably continue to use the with mixed features specifier less often than could be justified. Several studies suggest that a third or more of bipolar patients have at least one episode with mixed symptoms; some reports suggest that mixed mood states are more frequent in women than in men.
You can apply this specifier to episodes of major depression, mania, and hypomania (see Table 3.3). Because of the greater impairment and overall severity of mania symptoms, if you have a patient who meets full criteria for both mania and major depression, you should probably go with the diagnosis of bipolar I disorder with mixed features, rather than major depressive disorder with mixed features. Winona Fisk had bipolar I disorder with mixed features.
The criteria for with mixed features omit some of the mood symptoms found in manic and major depressive episodes. That’s because they might conceivably belongon both lists, and hence do not indicate a mixed presentation. These symptoms include certain problems with sleep, appetite/weight, irritability, agitation, and concentration. Note, by the way, that the patient must meet full criteria for major depressive, manic, or hypomanic episode.
The criteria are silent as to how long each day (or, actually, the majority of days) the mixed features must be present, and I don’t know of any data that would help us understand this question better. Right now, even a few minutes a day, repeated day after day, would seem enough to earn this specifier. Only additional research is going to help us understand whether that’s a sensible time frame—or too short, or too long. Right now, that picture is decidedly mixed.
Essential Features of With Mixed Features
Here, there are two ways to go.
A patient with a manic or hypomanic episode also has some noticeable symptoms of depression most days: depressed mood, low interest or pleasure in activities, an activity level that is speeded up or slowed down, feeling tired, feeling worthless or guilty, and repeated thoughts about death or suicide. (See Coding Note.)
A patient with major depressive episode also has some noticeable symptoms of mania most days: heightened mood, grandiosity, increased talkativeness, flight of ideas, increased energy level, poor judgment (such as excessive spending, sexual adventures, imprudent financial speculations), and reduced need for sleep.
The Fine Print
The D: • Differential diagnosis (physical disorders, substance use disorders)
Coding Note
The impairment and severity of full-blown mania suggest that patients who simultaneously meet full episode criteria for both manic and depressive episodes should be recorded as having manic episode, with mixed features.
With Peripartum Onset
Over half of all women have “baby blues” after giving birth: They may feel sad and anxious, cry, complain of poor attention, and have trouble sleeping. This lasts a week or two and is usually of little consequence. But about 10% of women have enough symptoms to be diagnosed as having a depressive disorder; these people often have a personal history of mental disorder. An episode of hypomania may be especially likely after childbirth. Only about 2 out of 1,000 new mothers actually become psychotic.
The with peripartum onset specifier has the briefest Essential Features in this book. Though Elisabeth Jacks had a manic episode after giving birth, a major depressive episode would be much the more common response. With peripartum onset can apply to bipolar I and bipolar II disorders, to either type of major depressive disorder, or to brief psychotic disorder (see Table 3.3 for all applications except to brief psychotic disorder).
Essential Features of With Peripartum Onset
A female patient’s mood disorder starts during pregnancy or within a month of giving birth.
Coding Notes
See Table 3.3 for application.
In the mood disorders, it’s called with peripartum onset. However, when it occurs with brief psychotic disorder, it’s called with postpartum onset, even though it’s described there as occurring “during pregnancy or within 4 weeks postpartum.” This is just one more little glitch that will probably get sorted out, by and by. Use it either way in any context, and you’re still likely to be understood.
With Psychotic Features
Irrespective of the severity rating, some patients with manic or major depressive episodes will have delusions or hallucinations. (Of course, most of these patients you will have rated as being severely ill, but it is at least theoretically possible that someone could have just a few symptoms—including psychosis—that for whatever reason haven’t hugely inconvenienced them.) Around half of patients with bipolar I disorder will have psychotic symptoms; far fewer patients with major depressive disorder will be psychotic.
Psychotic symptoms may be mood-congruent or mood-incongruent. Specify, if possible:
With mood-congruent psychotic features. The content of the patient’s delusions or hallucinations is completely in accord with the usual themes of the relevant mood episode. For major depression, these include death, disease, guilt, delusions of nihilism (nothingness), personal inadequacy, or punishment that is deserved; for mania, they include exaggerated ideas of identity, knowledge, power, self-worth, or relationship to God or someone else famous.
With mood-incongruent psychotic features. The content of the patient’s delusions or hallucinations is not in accord with the usual themes of the mood episode. For both mania and major depression, these include delusions of persecution, control, thought broadcasting, and thought insertion.
Essential Features of With Psychotic Features
The patient has hallucinations or delusions.
Coding Notes
Specify, if possible:
With mood-congruent psychotic features. The psychotic symptoms match what you’d expect from the basic manic or depressive mood (see above).
With mood-incongruent psychotic features. They don’t match.
Specifiers That Describe Episode Patterns
Two specifiers describe the frequency or timing of mood episodes. Their appropriate uses are summarized below in Table 3.3, as are those for the other types of specifiers.
With Rapid Cycling
Typically, the bipolar disorders follow a more or less indolent course: a number of months (perhaps 3–9) of depression, followed by somewhat fewer months of mania or hypomania. Other than their number, the individual episodes meet full criteria for major depressive, manic, or hypomanic episodes. As patients age, the entire cycle tends to speed up, but most patients have no more than one up-and-down cycle per year, even after five or more complete cycles. Some patients, however, especially women, cycle much more rapidly than this: They may go from mania to depression to mania again within a few weeks. (Their symptoms meet full mood episode requirements—that’s how they differ from cyclothymic disorder.)
Recent research suggests that patients who cycle rapidly are more likely to originate from higher socioeconomic classes; in addition, a past history of rapid cycling predicts that this pattern will continue in the future. Rapid cyclers may be more difficult to manage with standard maintenance regimens than other patients, and they may have a poorer overall prognosis. With rapid cycling can apply to bipolar I and bipolar II disorders.
Essential Features of With Rapid Cycling
A patient has four or more episodes per year of major depression, mania, or hypomania.
Coding Notes
To count as a separate episode, an episode must be marked by remission (part or full) for 2+ months or by a change in polarity (such as from manic to major depressive episode).
With Seasonal Pattern
Here is yet another specifier for mood disorders that has only been recognized in the last few decades. In the usual pattern, depressive symptoms (these are often also atypical) appear during fall or winter months and remit in the spring and summer. Patients with winter depression may report other difficulties, such as pain disorder symptoms or a craving for carbohydrates, during their depressed phase. Winter depressions occur more commonly in polar climates, especially in the far North, and younger people may be more susceptible. With seasonal pattern can apply to bipolar I and bipolar II disorders and to major depressive disorder, recurrent type. There may also be seasonality to manic symptoms, although this is far less well established. (Bipolar I patients may experience the seasonal pattern with one type of episode, not with the other.)
Sal Camozzi’s bipolar II disorder included a seasonal pattern. His history is presented in Chapter 11.
Essential Features of With Seasonal Pattern
The patient’s mood episodes repeatedly begin (and end) at about the same times of year. The seasonal episodes have been the only episodes for at least the past 2 years. Lifelong, seasonal episodes materially outnumber nonseasonal ones
The Fine Print
Disregard examples where there is a clear seasonal cause, such as being laid off every summer.
PUTTING IT ALL TOGETHER: CODING AND LABELING THE MOOD DISORDERS
Coding and labeling the mood disorders, especially major depressive disorder and bipolar I disorder, have always been complex undertakings—and DSM-5 and ICD-10 have further complicated them. Table 3.2 lays out the possible codes for bipolar I and major depressive disorders. A footnote to this table give two examples of how to label particular presentations of these disorders.
In addition to the three bipolar types listed in Table 3.2, there is also the possibility of bipolar I, unspecified type. That’s mainly intended for the folks in the record room when we neglect to indicate the polarity of the most recent episode. We clinicians should ordinarily have little occasion to use this code. Because the episode type is unknown, no episode specifiers can apply.
Table 3.3 summarizes all the descriptors and specifiers that can apply to mood disorders, and indicates with which disorders each modifier can be used.
DSM-5 doesn’t say that the depression of bipolar II disorder can have atypical, melancholic, or psychotic features. But neither does it say that it can’t. I say that if you encounter a patient with bipolar II disorder who has any of those features, step right up and declare it. It’ll do you a world of good.
OTHER SPECIFIED AND UNSPECIFIED MOOD DISORDERS
F31.89 [296.89] Other Specified Bipolar and Related Disorder
Use other specified bipolar and related disorder when you want to write down the specific reason your patient cannot receive a more definite bipolar diagnosis. To prevent overuse and “medicalization” of the normal ebb and flow of mood, the patient must have symptoms that don’t qualify for a more specific bipolar disorder diagnosis and that cause distress or interfere with the patient’s normal functioning. DSM-5 gives a number of examples:
Short-duration hypomanic episodes (2–3 days) and major depressive episodes. Such a patient will have had at least one fully qualified major depressive episode, plus at least one episode of hypomania too brief (2–3 days) to justify a diagnosis of bipolar II disorder. Because the depression and hypomania don’t occur together, a with mixed features designation wouldn’t be appropriate.
Hypomanic episodes with insufficient symptoms and major depressive episodes. Such a patient will have had least one major depressive episode but no actual manic or hypomanic episodes, though there will have been at least one episode of subthreshold hypomania. That is, the high phase is long enough (4 days or more) but is a symptom or two shy of the number required for a hypomanic episode (elevated mood plus one or two of the other symptoms of a hypomanic episode, or irritable mood plus two or three of the other symptoms of hypomania). The hypomanic and major depressive symptoms don’t overlap, so you can’t call it major depressive episode with mixed features.
Hypomanic episode without prior major depressive episode. Here you’d classify (no surprise) someone who has had an episode of hypomania but who hasn’t ever fully met criteria for a major depressive episode or a manic episode.
Short-duration cyclothymia. In a period less than 2 years (less than 12 months for a child or adolescent), such a patient will have had multiple episodes of both hypomanic symptoms and depressive symptoms, all of which will have been either too brief or have too few symptoms to qualify for a major depressive or hypomanic episode. Of course, there will be no manias and no symptoms of psychosis. Patients with short-duration cyclothymia will have symptoms for a majority of days and will have no symptom-free periods longer than 2 months.
F31.9 [296.80] Unspecified Bipolar and Related Disorder
And here you’d include patients for whom you don’t care to indicate the reason you aren’t diagnosing a well-defined bipolar condition.
F32.8 [311] Other Specified Depressive Disorder
Use other specified depressive disorder in the same way as described above for other specified bipolar and related disorder. DSM-5 provides the following examples of other specified depressive disorder:
Recurrent brief depression. Every month for 12+ months, lasting from 2 to 13 days at a time, these patients have low mood plus at least four other symptoms of depression that aren’t associated with menstruation. The patients have never fulfilled criteria for another mood disorder, and they’ve not been psychotic.
Short-duration depressive episode. These patients would meet criteria for major depressive episode except for duration—their episodes last 4–13 days. Here’s the full run-down: depressed mood; at least four other major depressive symptoms; clinically significant distress or impairment; have never met criteria for other mood disorders; not currently psychotic; and don’t meet criteria for other conditions.
Depressive episode with insufficient symptoms. These patients would meet criteria (duration, distress) for major depression, except that they have too few symptoms. They don’t have another psychotic or mood disorder.
F32.9 [311] Unspecified Depressive Disorder
As for unspecified bipolar and related disorder, when you don’t care to indicate the reason for a more secure diagnosis, you can use the unspecified depressive disorder category. The advantage: mood disorders “of uncertain etiology” have been used so often in the past as to undermine their value.
Whenever we clinicians encounter a patient with schizophrenia and postpsychotic depressive disorder, or one with a major depressive episode superimposed on a psychosis, we should think extra carefully about the diagnosis. Likewise, the occurrence of a manic episode in a patient who was formerly diagnosed as psychotic should cause us to wonder whether the original diagnosis was correct. In both cases, some of these patients may actually have bipolar I disorder, and not schizophrenia or another psychotic disorder at all. This would appear to be an ongoing problem, regardless of which edition of the DSM we are using.
*I suppose it’s possible that a patient with bipolar II disorder might end up hospitalized without really needing it. In that case, I’d go with the predominant symptoms and call it bipolar II.
CHAPTER 4
Quick Guide to the Anxiety Disorders
One or more of the following conditions may be diagnosed in patients who present with prominent anxiety symptoms; a single patient may have more than one anxiety disorder. As usual, link indicates where a more detailed discussion begins.
Primary Anxiety Disorders
Panic disorder . These patients experience repeated panic attacks—brief episodes of intense dread accompanied by a variety of physical and other symptoms, together with worry about having additional attacks and other related mental and behavioral changes.
Agoraphobia . Patients with this condition fear situations or places such as entering a store, where they might have trouble obtaining help if they became anxious.
Specific phobia . In this condition, patients fear specific objects or situations. Examples include animals; storms; heights; blood; airplanes; being closed in; or any situation that may lead to vomiting, choking, or developing an illness.
Social anxiety disorder . These patients imagine themselves embarrassed when they speak, write, or eat in public or use a public urinal.
Selective mutism . A child elects not to talk, except when alone or with select intimates.
Generalized anxiety disorder . Although they experience no episodes of acute panic, these patients feel tense or anxious much of the time and worry about many different issues.
Separation anxiety disorder . The patient becomes anxious when separated from a parent or other attachment figure.
Anxiety disorder due to another medical condition . Panic attacks and generalized anxiety symptoms can be caused by numerous medical conditions.
Substance/medication-induced anxiety disorder . Use of a substance or medication has caused panic attacks or other anxiety symptoms.
Other specified, or unspecified, anxiety disorder . Use these categories for disorders with prominent anxiety symptoms that don’t fit neatly into any of the groups above.
Other Causes of Anxiety and Related Symptoms
Obsessive–compulsive disorder . These patients are bothered by repeated thoughts or behaviors that can appear senseless, even to them.
Posttraumatic stress disorder . A severely traumatic event, such as combat or a natural disaster, is relived over and over.
Acute stress disorder . This condition is much like posttraumatic stress disorder, except that it begins during or immediately after the stressful event and lasts a month or less.
Avoidant personality disorder . These timid people are so easily wounded by criticism that they hesitate to become involved with others.
With anxious distress specifier for major depressive disorder . Some patients with major depressive disorder have much accompanying tension and anxiety.
Somatic symptom disorder and illness anxiety disorder . Panic and other anxiety symptoms are often part of somatic symptom disorder and illness anxiety disorder .
INTRODUCTION
The conditions discussed in this chapter are characterized by anxiety and the behaviors by which people try to ward it off. Panic disorder, the various phobias, and generalized anxiety disorder are collectively among the most frequently encountered of all mental disorders listed in DSM-5. Yet, in discussing them, we must also keep in mind three other facts about anxiety.
The first of these is that a certain amount of anxiety isn’t just normal, but adaptive and perhaps vital for our well-being and normal functioning. For example, when we are about to take an examination or speak in public (or write a book), the fear of failure spurs us on to adequate preparation. Similarly, normal fear lies behind our healthy regard for excessive debt, violent criminals, and poison ivy.
Anxiety is also a symptom—one that’s encountered in many, perhaps most, mental disorders. Because it is so dramatic, we sometimes focus our attention on the anxiety to the exclusion of historical data and other symptoms (depression, substance use, and problems with memory, to name just a few) that are crucial to diagnosis. I’ve interviewed countless patients whose anxiety symptoms have masked mood, somatic symptom, or other disorders—conditions that are often not only highly treatable when they are recognized, but deadly when they are not.
The third issue I want to emphasize is that anxiety symptoms can sometimes indicate the presence of a substance use problem, another medical condition, or even a different mental disorder altogether (such as a mood, somatic symptom, cognitive, or substance-related disorder). These conditions should be considered for any patient who presents with anxiety or avoidance behavior.
Once again, I’ve eschewed DSM-5’s organization, which seems to rely on the typical age of onset (most anxiety disorders begin when the patient is relatively young). Rather, I’ve started with panic attacks, because they are pervasive throughout the anxiety (and many other) disorders.
Panic Attack
Someone in the throes of a panic attack feels foreboding—a sense of disaster that is usually accompanied by cardiac symptoms (such as irregular or rapid heartbeat) and trouble breathing (shortness of breath, chest pain). The attack usually begins abruptly and builds rapidly to a peak; the whole, miserable experience usually lasts less than half an hour.
Here are several important facts about panic attacks:
• They are common (perhaps 30% of all adults have experienced at least one). In a 12-month period, over 10% of Americans will have one (though they are apparently about a third as common among Europeans).
• Women are more often affected than men.
• They can occur as isolated experiences in normal adults; in such cases, there is no diagnosis at all.
• Panic attacks may occur within a broad spectrum of frequency, from just a few episodes in the lifetime of some individuals to many times per week in others. Some people even awaken at night with nocturnal attacks.
• Untreated, they can be severely debilitating. Many patients change their behavior in reaction to the fear that the attacks mean they are psychotic or physically ill.
• Treatment is sometimes easy, perhaps just by providing a little reassurance or a paper bag to breathe into.
• But sometimes panic attacks mask other illnesses that range from mood disorders to heart attacks.
• Some panic attacks are triggered by specific situations, such as crossing a bridge or roaming a crowded supermarket. Such attacks are said to be cued or situationally bound. Others have no relationship to a specific stimulus but arise spontaneously, as in panic disorder. These are termed unexpected or uncued. A third type, situationally predisposed attacks, consists of attacks in which the patient often (but not invariably) becomes panic-stricken when confronted by the stimulus.
• The patient can be calm or anxious when the upswing in panic symptoms begins.
• By themselves, panic attacks are not codable. The criteria are given so that they can be identified and applied as a specifier to whatever disorder may be appropriate. Of course, they always occur in panic disorder, but there you don’t have to specify them: they go with the territory.
Pathological panic attacks usually begin in a person’s 20s. Panic attacks may occur without other symptoms (when they may qualify for a diagnosis of panic disorder) or in connection with a variety of other disorders, which may include agoraphobia, social anxiety disorder, specific phobia, posttraumatic stress disorder (PTSD), mood disorders, and psychotic disorders. They can also feature in anxiety disorder due to another medical condition and in substance-induced anxiety disorder.
Essential Features of Panic Attack
A panic attack is fear, sometimes stark terror, that begins suddenly and is accompanied by a variety of classic “fight-or-flight” symptoms, plus a few others—chest pain, chills, feeling too hot, choking, shortness of breath, rapid or irregular heartbeat, tingling or numbness, excessive perspiration, nausea, dizziness, and tremor. As a result, these people may feel unreal or be afraid that they are losing their minds or dying. At least four of the somatic sensations are required.
Coding Notes
Panic attack is not a codable disorder. It provides the basis for panic disorder, and it can be attached as a specifier to other diagnoses. These include posttraumatic stress disorder, other anxiety disorders, and other mental disorders (including eating, mood, psychotic, personality, and substance use disorders). They are even found in medical conditions affecting the heart, lungs, and gastrointestinal tract.
Shorty Rheinbold
Seated in the clinician’s waiting room, Shorty Rheinbold should have been relaxed. The lighting was soft, the music soothing; the sofa on which he was sitting was comfortably upholstered. Angel fish swam lazily in their sparkling glass tank. But Shorty felt anything but calm. Perhaps it was the receptionist—he wondered whether she was competent to handle an emergency with his sort of problem. She looked something like a badger, holed up behind her computer. For several minutes he had been feeling worse with every heartbeat.
His heart was the key. When Shorty first sat down, he hadn’t even noticed it, quietly ticking away, just doing its job inside his chest. But then, without any warning, it had begun to demand his attention. At first it had only skipped a beat or two, but after a minute, it had begun a ferocious assault on the inside of his chest wall. Every beat had become a painful, bruising thump that caused him to clutch at his chest. He tried to keep his hands under his jacket so as not to attract too much attention.
The pounding heart and chest pain could mean only one thing—after 2 months of attacks every few days, Shorty was beginning to get the message. Then, right on schedule, the shortness of breath began. It seemed to arise from his left chest area, where his heart was doing all the damage. It clawed its way up through his lungs and into his throat, gripping him around the neck so he could breathe only in the briefest of gulps.
He was dying! Of course, the cardiologist Shorty consulted the week before had assured him that his heart was as sound as a brass bell, but this time he knew it was about to fail. He couldn’t fathom why he hadn’t died before; he had feared it with every attack. Now it seemed impossible that he would survive this one. Did he even want to? That thought made him suddenly want to retch.
Shorty leaned forward so he could grip both his chest and his abdomen as unobtrusively as possible. He could hardly hold anything at all: The familiar tingling and numbness had started up in his fingers, and he could sense the shaking of his hands as they tried to contain the various miseries that had taken over his body.
He glanced across the room to see whether Miss Badger had noticed. No help was coming from that quarter; she was still pounding away at her keyboard. Perhaps all the patients behaved this way. Perhaps—suddenly, there was an observer. Shorty was watching himself! Some part of him had floated free and seemed to hang suspended, halfway up the wall. From this vantage point, he could look down and view with pity and scorn the quivering flesh that was, or had been, Shorty Rheinbold.
Now the Spirit Shorty saw that Shorty’s face had become fiery red. Hot air had filled his head, which seemed to expand with every gasp. He floated farther up the wall and the ceiling melted away; he soared out into the brilliant sunshine. He squeezed his eyes shut but could not keep out the blinding light.
Depression is so often found in patients who complain of recurrent panic attacks that the association cannot be overemphasized. Some studies suggest that over half the patients with panic disorder also have major depressive disorder. Clearly, we must carefully evaluate for symptoms of a mood disorder everyone who presents with panic symptoms.
Evaluation of Shorty Rheinbold
Shorty’s panic attack was typical: It began suddenly, developed rapidly, and included a generous helping of the required symptoms. His shortness of breath (criterion A4) and heart palpitations (A1) are classical panic attack symptoms; he also had chest pain (A6), lightheadedness (A8), and numbness in his fingers (A10). Shorty’s fear that he would die (A13) is typical of the fears that patients have during an attack. The sensation of watching himself (depersonalization—A11) is a less common symptom of panic. He needed only four of these symptoms to substantiate the fact of panic attack.
Shorty’s panic attack was uncued, which means that it seemed to happen spontaneously, without provocation. He was unaware of any event, object, or thought that triggered it. Uncued attacks are typical of panic disorder, which can also include cued (or situationally bound) attacks. The panic attacks that develop in social anxiety disorder and specific phobia are cued to the stimuli that repeatedly and predictably pull the trigger.
Panic attacks can occur in several medical conditions. One of these is acute myocardial infarction, the very condition many panic patients fear the most. Of course, when indicated patients with symptoms like Shorty’s should be evaluated for myocardial infarction and other medical disorders. These include low blood sugar, irregular heartbeat, mitral valve prolapse, temporal lobe epilepsy, and a rare adrenal gland tumor called a pheochromocytoma. Panic attacks also occur during intoxication with several psychoactive substances, including amphetamines, marijuana, and caffeine. (Note that in addition, some patients misuse alcohol or sedative drugs in an effort to reduce the severity of their panic attacks.)
There is no code number associated with panic attack. I’ll give Shorty’s complete diagnosis below.
F41.0 [300.01] Panic Disorder
Panic disorder is a common anxiety disorder in which the patient experiences unexpected panic attacks (usually many, but always more than one) and worries about having another. Though the panic attacks are usually uncued, situationally predisposed attacks and cued/situationally bound attacks also occur (see definitions, above). A strong minority will have nocturnal panic attacks as well as those that occur while awake. Perhaps half of patients with panic disorder also have symptoms of agoraphobia , though many do not.
Panic disorder typically begins during the patient’s early 20s. It is one of the most common anxiety disorders, found in 1–4% of the general adult population (10% is the approximate figure for panic attacks in general). It is especially common among women.
Essential Features of Panic Disorder
As a result of surprise panic attacks (see the preceding description), the patient fears that they will happen again or tries to avert further attacks by taking (ineffective) action, such as abandoning an once-favored activities or avoiding places where attacks have occurred.
The Fine Print
Don’t forget the D’s: • Duration (1+ months) • Distress or disability (as above) • Differential diagnosis (substance use and physical disorders, other anxiety disorders, mood and psychotic disorders, obsessive–compulsive disorder [OCD], PTSD, actual danger)
Shorty Rheinbold Again
Shorty opened his eyes to discover that he was lying on his back on the waiting room floor. Two people were bending over him. One was the receptionist. He didn’t recognize the other, but he guessed it must be the mental health clinician who was supposed to interview him.
“I feel like you saved my life,” he said.
“Not really,” the clinician replied. “You’re just fine. Does this happen often?”
“Every 2 or 3 days now.” Shorty cautiously sat up. After a moment or two, he allowed them to help him to his feet and into the inner office.
Just when his problem had begun wasn’t quite clear at first. Shorty was 24 and had spent 4 years in the Coast Guard. Since his discharge, he’d knocked around a bit, and then moved in with his folks while he worked in construction. Six months ago, he’d gotten a job as cashier in a filling station.
That was just fine, sitting in a glassed-in booth all day making change, running credit cards through the electronic scanner, and selling chewing gum. The wages weren’t exciting, but he didn’t have to pay rent. Even with eating out almost every evening, Shorty still had enough at the end of the week to take his girl out on Saturday nights. Neither one of them drank or used drugs, so even that didn’t set him too far back.
The problem had begun the day after Shorty had been working for a couple of months, when the boss told him to go out on the wrecker with Bruce, one of the mechanics. They had stopped along the eastbound Interstate to pick up an old Buick Skylark with a blown head gasket. For some reason, they had trouble getting it into the sling. Shorty was on the traffic side of the truck, trying to manipulate the hoist in response to Bruce’s shouted directions. Suddenly, a caravan of tractor-trailer trucks roared past. The noise and the blast of wind caught Shorty off guard. He spun around into the side of the wrecker, fell, and rolled to a stop, inches from huge tires rolling by.
Shorty’s color and heart rate had returned to normal. The remainder of his story was easy enough to tell. He continued to go out on the wrecker, even though he felt scared, near panic every time he did so. He’d only go when Bruce was along, and he carefully avoided the traffic side of the vehicles.
But that wasn’t the worst of the problem—he could always quit and get another job. Lately, Shorty had been having these attacks at other times, when he was least expecting them. Now nothing seemed to trigger the attacks; they just happened, though not when he was at home or in his glass cage at work. When he was shopping last week, he’d had to abandon the cart full of groceries he was buying for his mother. Now he didn’t even want to go to the movies with his girl. For the last few weeks he had suggested that they spend Saturday night at her place watching TV instead. She hadn’t complained yet, but he knew it was only a matter of time.
“I have just about enough strength to tough it out through the work day,” Shorty said. “But I’ve got to get a handle on this thing. I’m too young to spend the rest of my life like a hermit in a cave.”
Further Evaluation of Shorty Rheinbold
The fact that Shorty experienced panic attacks has already been established. They were originally associated with the specific situation of working around the wrecker. For months now, they occurred every few days, usually catching him unaware (panic disorder criterion A). Undoubtedly worried and concerned (B1), he had altered his activities with his girlfriend (B2). A number of medical conditions can cause panic attacks; however, a cardiologist had recently pronounced Shorty to be medically fit. Substance-induced anxiety disorder (C) is also eliminated by the history: Shorty didn’t use drugs or alcohol. (However, watch out for patients who “medicate” their panic attacks with drugs or alcohol.) With no other mental disorder more likely (D), his symptoms fully support a diagnosis of panic disorder.
But wait, as they say, there’s more, for which we’ll have to consider the symptoms of agoraphobia. Recently, Shorty feared all sorts of other situations that involved being away from home—driving, shopping, even going to the movies (agoraphobia criterion A)—which nearly always provoked panic (C). As a result, he either avoided the situations or had to be accompanied by Bruce or by his girlfriend (D). Shorty’s life space had already begun to contract as a result of his fears; without treatment, it would seem to be only a matter of time before he would have to quit his job and remain at home (G). These symptoms are typical; we won’t quibble about the exact duration, because they are so severe (F). They’ll fulfill the requirements for agoraphobia, provided that we can rule out other etiologies for his symptoms (H, I). Sure, we should ask to determine that driving him was the fear that help would be unavailable or that escape would be difficult (B), but knowing Shorty, I’m pretty sure of the answer.
The diagnosis of specific phobia or social anxiety disorder would seem unlikely, because the focus of Shorty’s anxiety was not a single issue (such as enclosed places) or a social situation. Patients with somatic symptom disorder also complain of anxiety symptoms (though they aren’t a diagnostic feature), but this is an unlikely diagnosis for a physically healthy man.
Although the vignette doesn’t address this possibility, major depressive disorder is comorbid with panic disorder in half of the cases. The danger lies in the often dramatic anxiety symptoms overshadowing subtle depressive symptoms, so that the clinician overlooks them completely. When the criteria for both an anxiety and a mood disorder are met, they should both be listed. Other anxiety disorders can be comorbid in panic disorder patients; these include generalized anxiety disorder and specific phobia.
Shorty’s mood was anxious, not depressed or irritable. I’d give him a GAF score of 61. His diagnosis would be as follows:
| F41.0 [300.01] | Panic disorder |
| F40.00 [300.22] | Agoraphobia |
It can be really hard to differentiate panic disorder and agoraphobia from other anxiety disorders that involve avoidance (especially specific phobia and social anxiety disorder). The final decision often comes down to clinical judgment, though the following sorts of information can help:
1. How many panic attacks does the patient have, and what type are they (cued, uncued, situationally predisposed)? Uncued attacks suggest panic disorder; cued attacks suggest specific phobia or social anxiety disorder. (But they can be intermixed.)
2. In how many situations do they occur? Limited situations suggest specific phobia or social anxiety disorder; attacks that occur in a variety of situations suggest panic disorder and agoraphobia.
3. Does the patient awaken at night with panic attacks? This is more typical of panic disorder.
4. What is the focus of the fear? If it is having a subsequent panic attack, panic disorder may be the correct diagnosis—unless the panic attacks occur only when the patient is, say, riding in an airplane, in which case you might correctly diagnose specific phobia, situational type.
5. Does the patient constantly worry about having panic attacks, even when in no danger of facing a feared situation (such as riding in an elevator)? This would suggest panic disorder and agoraphobia.
F40.00 [300.22] Agoraphobia
The agora was the marketplace to ancient Greeks. In contemporary usage, agoraphobia refers to the fear some people have of any situation or place where escape seems difficult or embarrassing, or where help might be unavailable if anxiety symptoms should occur. Open or public places such as theaters and crowded supermarkets qualify; so does travel from home. Persons with agoraphobia either avoid the feared place or situation entirely, or, if they must confront it, suffer intense anxiety or require the presence of a companion. In any event, agoraphobia is a concept the Greeks didn’t have a word for; it was first used in 1873.
Agoraphobia usually involves such situations as being away from home; standing in a crowd; staying home alone; being on a bridge; or traveling by bus, car, or train. Agoraphobia can develop rapidly, within just a few weeks, in the wake of a series of panic attacks, when fear of recurrent attacks causes the patient to avoid leaving home or participating in other activities. Some patients develop agoraphobia without any preceding panic attacks.
In recent years, estimates of the prevalence of agoraphobia have risen to the neighborhood of 1–2%. As with panic disorder, women are more susceptible than men; the disorder usually begins in the teens or 20s, though some patients have their first symptoms after the age of 40. Often panic attacks precede the onset of the agoraphobia. It is strongly heritable.
Essential Features of Agoraphobia
These patients almost invariably experience inordinate anxiety or dread when they have to be alone or away from home. Potentially, there’s an abundance of opportunity: riding a bus (or other mass transit), shopping, attending a theatrical entertainment. For some, it’s as ordinary as walking through an open space (flea market, playground), being part of a crowd, or standing in a queue. When you explore their thinking, these people are afraid that escape would be impossible or that help (in the event of panic) unavailable. So they avoid such situations or confront them only with a trusted friend or, if all else fails, endure them with lots of suffering.
The Fine Print
Don’t duck the D’s: • Duration (6+ months) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, other anxiety disorders, mood and psychotic disorders, OCD, PTSD, social and separation anxiety disorders, situational phobias, panic disorder)
Lucy Gould
“I’d rather have her with me, if that’s all right.” Lucy Gould was responding to the clinician’s suggestion that her mother wait outside the office. “By now, I don’t have any secrets from her.”
Since age 18, Lucy hadn’t gone anywhere without her mother. In fact, in those 6 years she’d hardly been anywhere at all. “There’s no way I could go out by myself—it’s like entering a war zone. If someone’s not with me, I can barely stand to go to doctor appointments and stuff like that. But I still feel awfully nervous.”
The nervousness Lucy complained of hadn’t included actual panic attacks; she never felt that she couldn’t breathe or was about to die. Rather, she experienced an intense motor agitation that had caused her to flee from shopping malls, supermarkets, and movie theaters. Nor could she ride on public transportation; buses and trains both terrified her. She had the feeling, vague but always present, that something awful would happen there. Perhaps she would become so anxious that she would pass out or wet herself, and no one would be able to help her. She hadn’t been alone in public since the week before her high school commencement. She had only been able to go up onto the platform to receive her diploma because she was with her best friend, who would know what to do if she needed help.
Lucy had always been a timid, rather sensitive girl. The first week of kindergarten, she had cried each time her mother left her by herself at school. But her father had insisted that she “toughen up,” and within a few weeks she had nearly forgotten her terror. She’d subsequently maintained a nearly perfect attendance record at school. Then, shortly after her 17th birthday, her father died of leukemia. Her terror of being away from home had begun within a few weeks of his funeral.
To make ends meet, her mother had sold their house, and they had moved into a condominium across the street from the high school. “It’s the only way I got through my last year,” Lucy explained.
For several years, Lucy had kept house while her mother assembled circuit boards at an electronics firm outside town. Lucy was perfectly comfortable in that role, even though her mother was away for hours at a time. Her physical health had been good; she had never used drugs or alcohol; and she had never had depression, suicidal ideas, delusions, or hallucinations. But a year ago Lucy had developed insulin-dependent diabetes, which required frequent trips to the doctor. She had tried to take the bus by herself, but after several failures—once, in the middle of traffic, she had forced the rear door open and sprinted for home—she had given up. Now her mother was applying for disability assistance so that she could remain at home to provide the aid and attendance Lucy required.
Evaluation of Lucy Gould
Because of her fears, which were inordinate and out of proportion to the actual danger (criterion E), Lucy avoided a variety of situations and places, including supermarkets, malls, buses, and trains (A). If she did go, she required a companion (D). She couldn’t state exactly what might happen—only that it would be awful and embarrassing (she might even lose bladder control) and that help might not be available (B). It is not unusual that her symptoms only came to light when another problem (diabetes) prevented her from staying at home; diabetes itself isn’t associated with agoraphobic fears (H). OK, you’ll have to read between the lines of the vignette to verify criteria C (the situations almost always provoke anxiety) and G (the patient experiences clinically important distress or impairment).
Lucy’s symptoms were too varied for specific phobia or social anxiety disorder. (Note also that in agoraphobia, the perceived danger emanates from the environment; in social anxiety disorder, it comes from the relationship with other people.) Her problem wasn’t that she feared being left alone, as would be the case with separation anxiety disorder (although when she was five she clearly had had elements of that diagnosis). She hadn’t had a major trauma, as would be the case in PTSD (the death of her father was traumatic, but her own symptoms didn’t focus on reliving this experience). There is no indication that she had OCD. And so (finally!) we have disposed of criterion I.
Agoraphobia can accompany a variety of diagnoses, the most important of which are mood disorders that involve major depressive episodes. However, Lucy denied having symptoms of depression, psychosis, and substance use. Although she had diabetes, it developed many years after her agoraphobia symptoms became apparent. Besides, it’s hard to imagine a physiological connection between agoraphobia and diabetes, and her anxiety symptoms were far more extensive than the realistic concerns you’d expect from the average diabetic individual.
Because Lucy had never experienced a discrete panic attack, she would not meet the criteria for panic disorder in addition to her agoraphobia. By the way, the fact that she was housebound would net her a low GAF score (31).
| F40.00 [300.22] | Agoraphobia |
| E10.9 [250.01] | Insulin-dependent diabetes mellitus |
Specific Phobia
Patients with specific phobias have unwarranted fears of specific objects or situations. The best recognized are phobias of animals, blood, heights, travel by airplane, being closed in, and thunderstorms. The anxiety produced by exposure to one of these stimuli may take the form of a panic attack or of a more generalized sensation of anxiety, but it is always directed at something specific. (However, these patients can also worry about what they might do—faint, panic, lose control—if they have to confront whatever it is they are afraid of.) Generally, the closer they are to the feared stimulus (and the more difficult it would be to escape), the worse they feel.
Patients usually have more than one specific phobia. A person who is about to face one of these feared activities or objects will immediately begin to feel nervous or panicky—a condition known as anticipatory anxiety. The degree of discomfort is often mild, however, so most people do not seek professional help. When it causes a patient to avoid feared situations, anticipatory anxiety can be a major inconvenience; it can even interfere with working. Patients with specific phobias involving blood, injury, or injection often experience what is called a vasovagal response; this means that reduced heart rate and blood pressure actually do cause the patients to faint.
In the general population, specific phobia is one of the most frequently reported anxiety disorders. Up to 10% of U.S. adults have suffered to some degree from one of these specific phobias. However, by no means would all of these people qualify for a DSM-5 diagnosis: The clinical significance of these reported fears is so hard to judge.
Onset is usually in childhood or adolescence; animal phobias especially tend to begin early. Some begin after a traumatic event, such as being bitten by an animal. A situational fear (such as being closed in or traveling by air) is more likely than other types of specific phobia to have a comorbid disorder such as depression and substance misuse, though comorbidity with a wide range of mental disorders is the rule. Females outnumber males, perhaps by a 2:1 ratio.
Essential Features of Specific Phobia
A specific situation or thing habitually causes such immediate, inordinate (and unreasonable) dread or anxiety that the patient avoids it or endures it with much anxiety.
The Fine Print
The D’s: • Duration (6+ months) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, agoraphobia, social anxiety disorder, separation anxiety disorder, mood and psychotic disorders, anorexia nervosa, OCD, PTSD)
Coding Notes
Specify all types that apply with individual ICD-10 codes:
F40.218 [300.29] Animal type (snakes, spiders)
F40.228 [300.29] Natural environment type (thunderstorms, heights)
Blood–injection–injury type (syringes, operations):
F40.230 [300.29] Blood
F40.231 [300.29] Injections and transfusions
F40.232 [300.29] Other medical care
F40.233 [300.29] Injury
F40.248 [300.29] Situational type (traveling by air, being closed in)
F40.298 [300.29] Other type (situations where the person could vomit or choke; for children, loud noises or people wearing costumes)
Esther Dugoni
A slightly built woman of nearly 70, Esther Dugoni was healthy and fit, though in the last year or two she had developed a tremor characteristic of early Parkinson’s disease. For the several years since she had retired from her job teaching horticulture in junior college, she had concentrated on her own garden. At the flower show the year before, her rhododendrons had won first prize.
But 10 days earlier, her mother had died in Detroit, over halfway across the country. She and her sister had been appointed co-executors. The estate was large, and she would have to make several trips to probate the will and dispose of the house. That meant flying, and this was why she had sought help from the mental health clinic.
“I can’t fly!” she had told the clinician. “I haven’t flown anywhere for 20 years.”
Esther had been reared during the Depression; as a child, she had never had the opportunity to fly. With five children of her own to care for on her husband’s schoolteacher pay, she hadn’t traveled much as an adult, either. She had made a few short hops years ago, when two of her children were getting married in different cities. On one of those trips, her plane had circled the field for nearly an hour, trying to land in Omaha between thunderstorms. The ride was wretchedly bumpy; the plane was full; and many of the passengers were airsick, including the men seated on either side of her. There was no one to help—the flight attendants had to remain strapped in their seats. She had kept her eyes closed and breathed through her handkerchief to try to filter out the odors that filled the cabin.
They finally landed safely, but it was the last time Esther had ever been up in an airplane. “I don’t even like to go to the airport to meet someone,” she reported. “Even that makes me feel short of breath and kind of sick to my stomach. Then I get sort of a dull pain in my chest and I start to shake—I feel that I’m about to die, or something else awful will happen. It all seems so silly.”
Esther really had no alternatives to flying. She couldn’t stay in Detroit until all of the business had been taken care of; it would take months. The train didn’t connect, and the bus was impossible.
Evaluation of Esther Dugoni
Esther’s anxiety symptoms were cued by the prospect of airplane travel (criterion A); even going to the airport inevitably produced anxiety (B), and she had avoided plane travel for years (C, E). She recognized that this fear was unreasonable (“silly”), and it embarrassed her (D); it was about to interfere with how she conducted her personal business (F).
Specific phobia is not usually associated with any general medical condition or substance-induced disorder. In response to delusions, patients with schizophrenia will sometimes avoid objects or situations (a telephone that is “bugged,” food that is “poisoned”), but such patients do not have the required insight that their fears are unfounded. Of course, specific phobias must be differentiated from fears associated with other disorders (such as agoraphobia, OCD, PTSD, social anxiety disorder—G). Esther’s clinician should ask about possible comorbid diagnoses. Pending that, and with a GAF score of 75, her diagnosis would be as given below. (Esther had only one phobia, a situational one; the average is three, each of which would be listed on a separate line with its own number.)
| F40.248 [300.29] | Specific phobia, situational (fear of flying) |
| G20 [332.0] | Parkinson’s disease, primary |
| Z63.4 [V62.82] | Uncomplicated bereavement |
Fears involving animals of one sort or another are remarkably common. Children are especially susceptible to animal phobias, and many adults don’t much care for spiders, snakes, or cockroaches. But a diagnosis of specific phobia, animal type, should not be made unless a patient is truly impaired by the symptoms. For example, you wouldn’t diagnose a snake phobia in a prisoner serving a life sentence—under which circumstances confrontation with snakes and activity restriction as a result would be unlikely.
F40.10 [300.23] Social Anxiety Disorder
Social anxiety disorder (SAD) is a fear of appearing clumsy, silly, or shameful. Patients dread social gaffes such as choking when eating in public, trembling when writing, or being unable to perform when speaking or playing a musical instrument. Using a public urinal will cause anxiety for some men. Fear of blushing affects especially women, who may not be able to put into words what’s so terrible about turning red. Fear of further choking is often acquired after an episode of choking on food; it can occur any time from childhood to old age. Some patients fear (and avoid) multiple such public situations.
Many people, men and women, have noticeable physical symptoms with SAD: blushing, hoarseness, tremor, and perspiration. Such patients may have actual panic attacks. Children may express their anxiety by clinging, crying, freezing, shrinking back, throwing tantrums, or refusing to speak.
Studies of general populations report a lifetime occurrence of SAD ranging from 4% to as high as 13%. However, if we consider only those patients who are truly inconvenienced by their symptoms, prevalence figures are probably lower. Whatever the actual figure, these findings contradict previous impressions that SAD is rare. Perhaps interviewers tend to overlook a common condition that patients silently endure. Though males outnumber females in treatment settings, women predominate in general population samples.
Onset is typically in the middle teens. The symptoms of SAD overlap with those of avoidant personality disorder; the latter is more severe, but both begin early, tend to last for years, and have some commonalities in family history. Indeed, SAD is reported to have a genetic basis.
Essential Features of Social Anxiety Disorder
Inordinate anxiety is attached to circumstances where others could closely observe the patient—public speaking or performing, eating or having a drink, writing, perhaps just speaking with another person. Because these activities almost always provoke disproportionate fear of embarrassment or social rejection, the patient avoids these situations or endures them with much anxiety.
The Fine Print
For children, these “others” must include peers, not just adults.
The D’s: • Duration (6+ months) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood and psychotic disorders, anorexia nervosa, OCD, avoidant personality disorder, normal shyness, and other anxiety disorders—especially agoraphobia)
Coding Notes
Specify if:
Performance only. The patient fears public speaking or performing, but not other situations.
Valerie Tubbs
“It starts right here, and then it spreads like wildfire. I mean, like real fire!” Valerie Tubbs pointed to the right side of her neck, which she kept carefully concealed with a blue silk scarf. “It” had been happening for almost 10 years, any time she was with people; it was worse if she was with a lot of people. Then she felt that everybody noticed.
Although she had never tried, Valerie didn’t think that her reaction was something she could control. She just blushed whenever she thought people were watching her. It had started during a high school speech class, when she had to give a talk. She had become confused about the difference between a polyp and a medusa, and one of the boys had commented on the red spot that had appeared on her neck. She had quickly flushed all over and had to sit down, to the general amusement of the class.
“He said it looked like a bull’s-eye,” she said. Since then, Valerie had tried to avoid the potential embarrassment of saying anything to more than a handful of people. She had given up her dream of becoming a fashion buyer for a department store, because she couldn’t tolerate the scrutiny the job would entail. Instead, for the last 5 years she had worked dressing mannequins for the same store.
Valerie said that it seemed “stupid” to be so afraid. It wasn’t just that she turned red; she turned beet-red. “I can feel prickly little fingers of heat crawling out across my neck and up my cheek. My face feels like it’s on fire, and my skin is being scraped with a rusty razor.” Whenever she blushed, she didn’t feel exactly panicky. It was a sense of anxiety and restlessness that made her wish her body belonged to someone else. Even the thought of meeting new people caused her to feel irritable and keyed up.
Evaluation of Valerie Tubbs
For years, Valerie had feared being embarrassed by the blushing that occurred whenever she spoke with other people (criteria A, B, C, and F in one sentence). Her fear was excessive (E), and she knew it—though insight isn’t required for the diagnosis. With her reluctance to speak publicly (and her scarf), she avoided exposure to scrutiny (D). Her anxiety also prevented her from working at the job she would have preferred (G).
With no actual panic attacks, and in the absence of anxiety disorder due to another medical condition and substance-induced anxiety disorder (H), determining her disorder would come down to the differential diagnosis of phobias (I). In the absence of a typical history, we can quickly dismiss specific phobia. People who have agoraphobia may avoid dining out because they fear the embarrassment of having a panic attack in a public restaurant. Then you would only diagnose SAD if it had been present prior to the onset of the agoraphobia and was unrelated to it. (Sometimes even clinicians who specialize in diagnosing and treating the anxiety disorders can have trouble deciding between these two diagnoses.) Patients with anorexia nervosa avoid eating, but the focus is on their weight, not on the embarrassment that might result from gagging or leaving food on their lips.
It is important to differentiate SAD from the ordinary shyness that is so common among children and other young people; this shows the value of the criterion that symptoms must be present for at least half a year, required by DSM-5 for adults as well as for children. Also keep in mind that many people worry about or feel uncomfortable with social activities such as speaking in public (stage fright or microphone fright). They should not receive this diagnosis unless it in some important way affects their working, social, or personal functioning.
Social phobia (as SAD used to be called) is often associated with suicide attempts and mood disorders. Anyone with SAD may be at risk for self-treatment with drugs or alcohol; Valerie’s clinician should ask carefully about these conditions. SAD has elements in common with avoidant personality disorder, which, often comorbid in these patients, may be a warranted diagnosis in a patient who is generally inhibited socially, is overly sensitive to criticism, and feels inadequate. Other mental disorders you might sometimes need to rule out—no problem for Valerie—would include panic disorder, separation anxiety disorder, body dysmorphic disorder, and autism spectrum disorder.
Valerie’s fears involved far more than performances, so the specifier wouldn’t apply. With a GAF score of 61, her diagnosis would be as follows:
| F40.10 [300.23] | Social anxiety disorder |
F94.0 [313.23] Selective Mutism
Selective mutism denotes children who remain silent except when alone or with a small group of intimates. The disorder typically begins during preschool years (ages 2–4), after normal speech has developed. Such a child, who speaks appropriately at home among family members but becomes relatively silent when among strangers, may not attract clinical attention until formal schooling begins. Although often shy, most such children have normal intelligence and hearing. When they do speak, they tend to use normal articulation, sentence structure, and vocabulary. The condition often improves spontaneously within weeks or months, though no one knows how to identify such a patient in advance of improvement.
Selective mutism is uncommon, with a prevalence of under 1 in 1,000; it appears to affect girls and boys about equally. Family history is often positive for social anxiety disorder and relatives with selective mutism. Comorbid conditions include other anxiety disorders (especially separation anxiety disorder and social anxiety disorder). They do not tend to have externalizing disorders, such as oppositional defiant or conduct disorder.
Essential Features of Selective Mutism
Despite speaking normally at other times, the patient regularly doesn’t speak in certain situations where speech is expected, such as in class.
The Fine Print
The first month of a child’s first year in school is often fraught with anxiety; exclude behaviors that occur during this time.
The D’s: • Duration (1+ months) • Distress or disability (social or work/academic impairment) • Differential diagnosis (unfamiliarity with the language to be used, a communication disorder such as stuttering, psychotic disorders, autism spectrum disorder, social anxiety disorder)
F93.0 [309.21] Separation Anxiety Disorder
For years, separation anxiety disorder (SepAD) was diagnosed in childhood—and stayed there. More recently, however, evidence has accumulated that the condition also affects adults. This can happen in two ways. Perhaps one-third of children with SepAD continue to have symptoms of the disorder well into their adult years. However, some patients develop symptoms de novo in their late teens or even later—sometimes even beginning in old age. SepAD has a lifetime prevalence of about 4% for children and 6% for adults; for adults, the 12-month prevalence is nearly 2%. It is more common in females than in males, though boys are more likely to be referred for treatment.
In children, SepAD may begin with a precipitant such as moving to a new home or school, a medical procedure or serious physical diagnosis, or the loss of an important friend or pet (or a parent). Symptoms often show up as school refusal, but younger children may even show reluctance at being left with a sitter or at day care. Children may enlist physical complaints, imagined or otherwise, as justification for remaining home with parents.
Adults, too, may fear that something horrible will happen to an important attachment figure—perhaps a spouse, or even a child. As a result, they are reluctant to leave home (or any place of safety); they may fear even sleeping alone, and they experience nightmares about separation. When apart from the principal attachment figure, they may need to telephone or otherwise touch base several times a day. Some may try to ensure safety by setting up a routine of following the other person.
When the onset is early in childhood, this condition is likely to remit; with later onset, symptoms are more likely to continue into adulthood and to confer more severe disability (though the intensity may wax and wane). Children with SepAD tend to drift into subclinical forms or nonclinical status. Most adults and children also have other disorders (especially mood, anxiety, and substance use disorders), though SepAD is often the condition present the longest.
Children with SepAD often have parents with an adult form of the same disorder, and, as with most anxiety disorders, there is a strong genetic component.
Essential Features of Separation Anxiety Disorder
Because they fear what might happen to a parent or someone else important in their lives, these patients resist being alone. They imagine that the parent will die or become lost (or that they will), so that even the thought of separation can cause anxiety, nightmares, or perhaps vomiting spells or other physical complaints. They are therefore reluctant to attend school, go out to work, or to sleep away from home—perhaps even in their own beds.
The Fine Print
The D’s: • Duration (6+ months in adults, though extreme symptoms—such as total school refusal—could justify diagnosis after a shorter duration; 4+ weeks in children) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (mood disorders, other anxiety disorders, PTSD)
Nadine Mortimer
At age 24, Nadine Mortimer still lived at home. The only reason for her evaluation, she told the clinician, was that her mother and stepfather had just signed on to join the Peace Corps; she, Nadine, would be left behind. “I just know I won’t be able to stand it.” She sobbed into her Kleenex.
Being alone had frightened Nadine from the time she was very small. She thought she could trace it back to her father’s death: He was a mechanic who drove a racing car for fun until the weekend he encountered a wall at the far turn of their hometown track. Her mother’s response was strangely stoic. “I think I took on the job of grieving for both of us,” Nadine commented. Within the year, her mother had remarried.
Her first day of first grade, Nadine had been so fearful that her mother had stayed in the classroom. “I was afraid something terrible would happen to her too, and I wanted to be there, for safety.” After several weeks, Natalie had been able to tolerate being left, but the following year, she threw up when Labor Day rolled around. After a few miserable weeks in second grade, she was withdrawn and home-schooled.
In 10th grade, she was reading and doing math at 12th-grade level. “But my socialization skills were near nil. I’d never even been to a sleepover at another girl’s house,” she said. So her parents bribed her with a cell phone and a promise that she could call any time. By the time Nadine was in junior college—hardly farther away than her high school—she’d negotiated for a smart phone with a GPS device; now she could track her mother’s whereabouts to within a few feet. With that, she said, she could “roam comfortably, stores and whatnot, as long as I could check Mom’s location whenever I wished.” Once, when her battery died, she had suffered a panic attack.
Nonetheless, she still didn’t graduate from junior college, and after a semester she returned home to be with her mother. “I know it seems weird,” she told the interviewer, “but I always imagine that someday she won’t come home to me. Just like Daddy.”
Evaluation of Nadine Mortimer
From the time she started school (criterion B), Nadine had had clear symptoms of SepAD. She worried that harm might befall her mother and was severely distressed when they were separated; she’d vomited at the mere prospect of a new school year (A). As a result, she had almost no friends and had never slept away from home (C). There was no sign of other disorders to exclude (D).
Modified by her adult status, many of these same symptoms persisted—panic symptoms when she couldn’t keep close tabs on her mother, from whom she refused to live apart. She even retained the same fear of harm befalling her mother if they ever were separated. The prospect of her parents’ leaving for a new career deeply affected her. Even if Nadine hadn’t had symptoms as a child, her adult disorder was troubling enough to qualify for the diagnosis of SepAD.
A significant problem remains in the differential diagnosis of SepAD: How does one distinguish it from agoraphobia? There is some overlap, but patients with SepAD are afraid of being away from a parent or other significant person, whereas the fear for a person with agoraphobia is of being in a place from which escape will be difficult. The mute testimony of her smart phone suggests that Nadine’s anxiety was of the former type, not the latter. I would put her current GAF score at 45.
| F93.0 [309.21] | Separation anxiety disorder |
The DSM-IV criteria for SepAD employed a number of behaviors only appropriate to children; perhaps this explains why it wasn’t recognized in adults earlier. Even now, panic symptoms may sometimes draw clinicians off the scent of adult SepAD.
F41.1 [300.02] Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) can be hard to diagnose. The symptoms are relatively unfocused; the nervousness is low-key and chronic; panic attacks are not required. Furthermore, it is, after all, just worry, and that’s something that touches all of us. But there are differences. Ordinary worry is somehow less serious; we are able (well, most of the time) to put it aside and concentrate on other, more immediate issues. The worry of GAD often starts of its own accord, seemingly without cause. And GAD worry is at times hard to control. It carries with it a collection of physical symptoms that pile onto the sense of agitated restlessness in a cascade of misery.
Although some patients with GAD may be able to state what it is that makes them nervous, others cannot. GAD worry is typically about far more issues (“everything”) than objective facts can justify. The disorder typically begins at about 30 years of age; many patients with GAD have been symptomatic for years without coming to the attention of a clinician. Perhaps this is because the degree of impairment in GAD is often not all that severe. Genetic factors play an important role in the development of GAD. It is found in up to 9% of the general adult population (lifetime risk), and, as with nearly every other anxiety disorder, females predominate.
Essential Features of Generalized Anxiety Disorder
Hard-to-control, excessive worrying about a variety of issues—health, family problems, money, school, work—results in physical and mental complaints: muscle tension, restlessness, becoming easily tired and irritable, experiencing poor concentration, and trouble with insomnia.
The Fine Print
The D’s: • Duration (on most days for 6+ months) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood disorders, other anxiety disorders, OCD, PTSD, realistic worry)
Bert Parmalee
For most of his adult life, Bert had been “a worry-wart.” At age 35, he still had dreams that he was flunking all of his college electrical engineering courses. But recently he had felt that he was walking a tightrope. For the past year he had been the administrative assistant to the chief executive officer of a Fortune 500 company, where he had previously worked in product engineering.
“I took the job because it seemed a great way to move up the corporate ladder,” he said, “but almost every day I have the feeling my foot’s about to slip off the rung.”
Each of the company’s six ambitious vice-presidents saw Bert as a personal pipeline to the CEO. His boss was a hard-driving workaholic who constantly sparked ideas and wanted them implemented yesterday. Several times he had told Bert that he was pleased with his performance. In fact, Bert was doing the best job of any administrative assistant he had ever had, but that didn’t seem to reassure Bert.
“I’ve felt uptight just about every day since I started this job. My chief expects action and results. He has zero patience for thinking about how it should all fit together. Our vice-presidents all want to have their own way. Several of them hint pretty broadly that if I don’t help them, they’ll put in a bad word with the boss. I’m always looking over my shoulder.”
Bert had trouble concentrating at work; at night he was exhausted but had trouble getting to sleep. Once he did, he slept fitfully. He had become chronically irritable at home, yelling at his children for no reason. He had never had a panic attack, and he didn’t think he was depressed. In fact, he still took a great deal of pleasure in the two activities he enjoyed most: Sunday afternoon football on TV and Saturday night lovemaking with his wife. But recently, she had offered to take the kids to her mother’s for a few weeks, to relieve some of the pressure. This only resurrected some of his old concerns that he wasn’t good enough for her—that she might find someone else and leave him.
Bert was slightly overweight and balding, and he looked apprehensive. He was carefully dressed and fidgeted a bit; his speech was clear, coherent, relevant, and spontaneous. He denied having obsessions, compulsions, phobias, delusions, or hallucinations. On the MMSE, he scored a perfect 30. He said that his main problem—his only problem—was his nagging uneasiness.
Valium made him drowsy. He had tried meditating, but it only allowed him to concentrate more effectively on his problems. For a few weeks he had tried having a cocktail before dinner; that had both relaxed him and prompted worries about alcoholism. Once or twice he even went with his brother-in-law to an Alcoholics Anonymous meeting. “Now I’ve decided to try dreading one day at a time.”
Evaluation of Bert Parmalee
Bert worried about multiple aspects of his life (his job, being an alcoholic, losing his wife); each of these worries was excessive for the facts (criterion A). The excessiveness of his worries would differentiate them from the usual sort of anxiety that is not pathological. Despite repeated efforts (meditation, medication, reassurance), he had been unable to control these fears (B). In addition, he had at least four physical or mental symptoms (only three are required): trouble concentrating (C3), fatigue (C2), irritability (C4), and sleep disturbance (C6). He had been having difficulty nearly every day for longer than the required 6 months (A). And his symptoms caused him considerable distress, perhaps even more than is usual for patients with GAD (D).
One of the difficulties in diagnosing GAD is that so many other conditions must be excluded (E). A number of physical conditions can cause anxiety symptoms; a complete workup of Bert’s anxiety would have to consider these possibilities. From the information contained in the vignette, a substance-induced anxiety disorder would appear unlikely.
Anxiety symptoms can be found in nearly every category of mental disorder, including psychotic, mood (depressed or manic), eating, somatic symptom, and cognitive disorders. From Bert’s history, none of these would seem remotely likely (F). For example, an adjustment disorder with anxiety would be eliminated because Bert’s symptoms met the criteria for another mental disorder.
It is important that the patient’s worry and anxiety not focus solely on feature of another mental disorder, especially another anxiety disorder. For example, it shouldn’t be “merely” worry about weight gain in anorexia nervosa, about contamination (OCD), separation from attachment figures (separation anxiety disorder), public embarrassment (social anxiety disorder), or having physical symptoms (somatic symptom disorder). Nevertheless, note that a patient can have GAD in the presence of another mental disorder—most often, mood and other anxiety disorders—provided that the symptoms of GAD are independent of the other condition.
The only specifier for GAD is is the optional with panic attacks. Bert’s diagnosis, other than a GAF score of 70, would be a plain vanilla:
| F41.1 [300.02] | Generalized anxiety disorder |
It is reasonable to ask this question: Does diagnosing GAD in a depressed patient help with your evaluation? After all, the anxiety symptoms may disappear once the depression has been sufficiently treated. The value, I suppose, is that flagging the anxiety symptoms gives a more complete picture of the patient’s pathology. Also, you may have to treat the anxiety symptoms independently later on.
Substance/Medication-Induced Anxiety Disorder
When the symptoms of anxiety or panic can be attributed to the use of a chemical substance, make the diagnosis of substance/medication-induced anxiety disorder. It can occur during acute intoxication (or heavy use, as with caffeine) or during withdrawal (as with alcohol or sedatives), but the symptoms must be more severe that you’d expect for ordinary intoxication or withdrawal, and they must be serious enough to warrant clinical attention.
Many substances can produce anxiety symptoms, but those most commonly associated are marijuana, amphetamines, and caffeine. See Table 15.1 in Chapter 15 for a summary of the substances for which intoxication or withdrawal can be expected to create anxiety. If more than one substance is involved, you’d code each separately. Quite frankly, these disorders are probably rare.
Essential Features of Substance/Medication-Induced Anxiety Disorder
The use of some substance appears to have caused the patient to experience anxiety symptoms or panic attacks.
The Fine Print
For tips on identifying substance-related causation, see sidebar .
The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (ordinary substance intoxication or withdrawal, delirium, physical disorders, mood disorders, and other anxiety disorders)
Coding Notes
Specify:
With onset during {intoxication}{withdrawal}. This gets tacked on at the end of your string of words.
With onset after medication use. You can use this in addition to other specifiers.
For specific coding procedures, see Tables 15.2 and 15.3 in Chapter 15 .
Bonita Ramirez
Bonita Ramirez, a 19-year-old college freshman, was brought to the emergency room by two friends. Alert, intelligent, and well informed, she cooperated fully in providing the following information.
Bonita’s parents both held graduate degrees and were well established in their professions. They lived in a well-to-do suburb of San Diego. Bonita was their oldest child and only daughter. Strictly reared in the Catholic faith, she hadn’t been allowed to date until a year before. Until sorority rush week, the only alcohol she had tasted had been Communion wine. By her account and that of her companions, she had been happy, healthy, and vivacious when she arrived on campus a fortnight earlier.
Two weeks had made a remarkable difference. Bonita now sat huddled on the examination table, feet drawn up beneath her. With her arms wrapped around her knees, she trembled noticeably. Although it was only September, she wore a sweater and complained of feeling cold. She kept reaching for the emesis basin beside her, as though she might need it again.
Her voice quavered as she said that nothing like this had ever happened to her before. “I had some beer last week. It didn’t bother me at all, except I had a headache the next morning.”
This evening there had been a “big sister, little sister” party at the sorority Bonita had just pledged. She had drunk some beer, and that had prompted her to take a few hits from the marijuana cigarette they were passing around. The beer must have numbed her throat, because she had been able to draw the smoke deep into her lungs and hold it, the way her friends had showed her.
For about 10 minutes Bonita hadn’t noticed anything at all. Then her head began to feel tight, as though her hair was a wig that didn’t fit right. Suddenly, when she tried to inhale, her chest “screamed in pain,” and she became instantly aware that she was about to die. She tried to run, but her rubbery legs refused to support her.
The other girls hadn’t had much experience with drug reactions, but they called one of the men from the fraternity house next door, who came over and tried to talk Bonita down. After an hour, she still felt the panicked certainty that she would die or go mad. That was when they decided to bring her to the emergency room.
At length she said, “They said it would relax me and expand my consciousness. I just want to contract it again.”
Evaluation of Bonita Ramirez
Bonita’s history—she was healthy until the ingestion of a substance that is known to produce anxiety symptoms, especially in a naïve user—is a dead giveaway for the diagnosis (criteria A, B). Other drugs that commonly produce anxiety symptoms include amphetamines, which can also produce panic attack symptoms, and caffeine when used heavily. However, because anxiety symptoms can be encountered at some point during the use of most substances, you can code an anxiety disorder secondary to the use of nearly any of them, provided that the anxiety symptoms are worse than you would expect for ordinary substance withdrawal or intoxication. Because she required emergency evaluation and treatment, we would judge this to be the case for Bonita (E).
Despite the proximity of the development of her symptoms to substance use (C), her clinician would want to be sure that she did not have another medical condition (or treatment with medication for a medical condition) that could also explain her anxiety symptoms.
Although she was severely panicked when she arrived at the emergency room, I would score Bonita’s GAF as a relatively high 80, because her symptoms had caused her no actual disability (plenty of distress) and should be transient; other diagnosticians might disagree. She had not used pot before, so she had no use disorder, and her code comes from the “none” row for cannabis in Table 15.3 .
| F12.980 [292.89] | Cannabis-induced anxiety disorder, with onset during intoxication |
F06.4 [293.84] Anxiety Disorder Due to Another Medical Condition
Many medical disorders can produce anxiety symptoms, which will usually resemble those of panic disorder or generalized anxiety disorder. Occasionally, they may take the form of obsessions or compulsions. Most anxiety symptoms won’t be caused by a medical disorder, but it is supremely important to identify those that are. The symptoms of an untreated medical disorder can evolve from anxiety to permanent disability (consider the dangers of a growing brain tumor).
Essential Features of Anxiety Disorder Due to Another Medical Condition
A physical medical condition appears to have caused panic attacks or marked anxiety.
The Fine Print
For pointers on deciding when a physical condition may have caused a disorder, see sidebar .
The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use disorders, delirium, mood disorders, other anxiety disorders, adjustment disorder)
Coding Notes
In recording the diagnosis, use the name of the responsible medical condition, and list first the medical condition, with its code number.
Millicent Worthy
“I wonder if we could just leave the door open.” Millicent Worthy got up from the chair and opened the examining room door. She had fidgeted throughout the first part of the interview. Part of that time, she had hardly seemed to be paying attention at all. “I feel better not being so closed in.” Once she finally settled down, she told this story.
Millicent was 24 and divorced. She had never touched drugs or alcohol. In fact, until about 4 months ago, she’d been well all her life. She had visited a mental health clinic only once before, when she was 12: Her parents were having marital problems, and the entire family had gone for family counseling.
She had first felt nervous while tending the checkout counter at the video rental outlet where she worked. She felt cramped, hemmed in, as if she needed to walk around. One afternoon, when she was the only employee in the store and she had to stay behind the counter, her heart began to pound and she perspired and became short of breath. She thought she was about to die.
Over the next several weeks, Millicent gradually became aware of other symptoms. Her hand had begun to shake; she noticed it one day at the end of her shift when she was adding up the receipts from her cash register. Her appetite was voracious, yet in the past 6 weeks her weight had dropped nearly 10 pounds. She still loved watching movies, but lately she felt so tired at night that she could barely keep awake in front of the TV. Her mood had been somewhat irritable.
“As I thought about it, I realized that all this started about the time my boyfriend and I decided to get married. We’ve been living together for a year, and I really love him. But I’d been burned before, in my first marriage. I thought that might be what was bothering me, so I gave back his ring and moved out. If anything, I feel worse now than before.”
Several times during the interview Millicent shifted restlessly in her chair. Her speech was rapid, though she could be interrupted. Her eyes seemed to protrude slightly, and although she had lost weight, a fullness in her neck suggested a goiter. She admitted that she was having trouble tolerating heat. “There’s no air conditioner in our store. Last summer it was no problem—we kept the door open. But now it’s terrible! And if I wore any less clothing to work, they’d have to give me a desk in the adult video section.”
Millicent’s thyroid function studies proved to be markedly abnormal. Within 2 months an endocrinologist had brought her hyperactive thyroid under control, and her anxiety symptoms had disappeared completely. Six months later, she and her fiancé were married.
Evaluation of Millicent Worthy
Millicent had at least one panic attack (criterion A); her distress was palpable (E). The only remaining requirements would involve ruling out other causes of her problem.
If she had had repeated panic attacks and if the symptoms of her goiter had been overlooked, she could have been misdiagnosed as having panic disorder. Her restlessness could have been misinterpreted as generalized anxiety disorder; her feelings of being closed in sound like a specific phobia. (Even Millicent interpreted her own symptoms as psychological, C.) Such scenarios reinforce the wisdom of placing physical conditions at the top of the list of differential diagnoses.
Irritability, restless hyperactivity, and weight loss also suggest a manic episode, but these are usually accompanied by a subjective feeling of high energy, not fatigue. Millicent’s rapid speech could be interrupted; in bipolar mania, often it cannot. Her lack of previous depressions or manias would also militate against any mood disorders. Her history rules out a substance/medication-induced anxiety disorder. And her attention span and orientation were good, so that we can disregard delirium (D). Finally, we know that the physiological effects of hyperthyroidism can cause anxiety symptoms of the sort Millicent experienced (B).
The broken engagement was noted not because it seemed a cause of her anxiety symptoms, but because her relationship with her fiancé was a problem that should be addressed as part of the overall treatment plan. I’d put her GAF score at an almost-healthy, but still-needs-to-be-addressed 85.
| E05.00 [242.00] | Hyperthyroidism with goiter without thyroid storm |
| F06.4 [293.84] | Anxiety disorder due to hyperthyroidism |
| Z63.0 [V61.10] | Estrangement from fiancé |
F41.8 [300.09] Other Specified Anxiety Disorder
Patients who have prominent symptoms of anxiety, fear, or phobic avoidance that don’t meet criteria for any specific anxiety disorder can be coded as having other specified anxiety disorder—and the reason for not including them in a better-defined category should be stated. DSM-5 suggests several different possibilities:
Insufficient symptoms. This would include panic attacks or GAD with too few symptoms.
The presentation is atypical.
Cultural syndromes. DSM-5 mentions several in an appendix on page 833.
F41.9 [300.00] Unspecified Anxiety Disorder
