Mood Disorders

1
Mood Disorders

• Part II

2
Episodes

• Major Depressive Episode
• Manic Episode
• Hypomanic Episode
• Mixed Episode
• These are the building blocks for the mood D/Os.
  They themselves are not coded, but are the
  components of the coded D/Os.

3
Major Depressive Disorder (296.xx)

• One or more Major Depressive Episodes (i.e. 2
  weeks or more of depressed mood 4 additional
  symptoms of depression)
• No history of Manic, Hypomanic or Mixed Episodes

4
Major Depressive Disorder (296.xx)

• Associated features
• High mortality rate
• About 15 of those with this disorder commit
  suicide
• Culture, Age Gender
• There may be different types of symptoms in
  different cultures
• There may also be different attitudes in
  expressing depressive feelings in different
  cultures
• Increased somatic complaints in children
• Increased cognitive symptoms in adults
• Occurs twice as frequently in women as men

5
Major Depressive Disorder (296.xx)

• Course
• Can begin at any age
• Mean onset in mid-20s
• Variable course in most individuals
• Episodes end completely in about 2/3 of those
  diagnosed with this D/O
• However, the incidence of one episode increases
  the chance of another episode, with the
  probability increasing for each subsequent
  episode (e.g. it gets progressively worse if not
  treated).

6
Major Depressive Disorder (296.xx)

• Differential diagnosis
• Rule out medical condition and substance/medicatio
  n use
• Differentiate from Dysthymic Disorder by
  severity, chronicity and persistence
• Can be given with Maj. Dep. D/O if the symptoms
  occurred for 2 years without a Depressive
  Episode, or if the Maj. Dep. D/O is in remission
  for 2 months before the onset of the Dysthymia

7
Major Depressive Disorder (296.xx)

• Differential diagnosis
• Schizoaffective Disorder
• There must be a two week period of psychotic
  symptoms outside of a mood episode
• Psychotic D/O
• There may be some symptoms of depression in those
  with these D/O. However, if the criteria are met
  for a Depressive Episode, the addition diagnosis
  of Depressive D/O NOS is added.

8
Major Depressive D/OCourse specifiers

• 4th Digit
• 296.2x
• Single episode
• 296.3x
• Recurrent episodes

9
Major Depressive D/OSeverity Specifier

• 5th digit
• Clinical status of current (or most recent) mood
• 296.21 Single episode, mild
• 296.22 Single episode, moderate
• 296.23 Single episode, severe without psychotic
  symptoms
• 296.24 Single episode, severe with psychotic
  symptoms
• 296.25 Single episode, in partial remission
• 296.26 Single episode, in full remission
• 296.20 Single episode, unspecified

10
Major Depressive Bipolar D/OFeatures Specifier

• Catatonic
• Waxy flexibility or stupor
• Excessive motor activity that does not appear to
  be externally influenced
• Rigid posture
• Mutism
• Other peculiarities of voluntary movement
• Echolalia
• Echopraxia

11
Major Depressive Bipolar D/OFeatures Specifier

• Melancholic
• Loss of pleasure in all or almost all activities
• Mood does not improve, even when something good
  happens
• Distinctive depressed mood (different from
  bereavement or feeling sad)
• Depression worse in the morning
• Early morning awakening
• Psychomotor retardation or agitation
• Significant anorexia or weight loss
• Excessive or inappropriate guilt

12
Major Depressive Bipolar D/OFeatures Specifier

• Atypical
• Mood reactivity
• Significant weight gain or increase in appetite
• Hypersomnia
• Leaden paralysis
• Long standing pattern of interpersonal rejection
  sensitivity (pathological sensitivity to being
  rejected by others) resulting in impaired social
  or occupational functioning

13
Major Depressive Bipolar D/OAdditional Course
Specifiers

• Rapid Cycling
• 4 episodes of a Mood Episode in the past 12
  months
• There is a 2 month partial or full remission
  between episodes, or episodes switch to the
  opposite polarity
• Longitudinal
• With full interepisode recovery
• Without full interepisode recovery

14
Major Depressive Bipolar D/OAdditional Course
Specifiers

• Postpartum onset
• Depressive episode which occurs within 4 weeks of
  giving birth
• Seasonal pattern
• There is a regular temporal relationship between
  the onset of the Mood D/O and a particular time
  of year
• Full remission occur in between seasonal episodes
  (or a shift from depression to mania)
• Seasonal episode outnumber non-seasonal episodes

15
Dysthymic Disorder (300.4)

• 2 years of depressed mood more days than not
• During periods of depressed mood, at least 2 of
  the following are present
• Poor appetite or over eating
• Insomnia or hypersomnia
• Low energy/fatigue
• Low self esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness
• Symptom free intervals last no more than 2 months
• No Manic, Hypomanic or Mixed Episodes

16
Dysthymic Disorder (300.4)

• Specifiers
• Early Onset
• Before age 21 years
• Increased risk of developing Maj. Dep. D/O
• Late Onset
• Age 21 or older
• With Atypical Features
• Same criteria as with Maj. Dep. D/O

17
Dysthymic Disorder (300.4)

• Associated features
• Feelings of inadequacy
• Generalized loss of interest
• Social withdrawal
• Feelings of guilt or brooding about the past
• Subjective irritability or anger
• Decreased activity or productiveness

18
Dysthymic Disorder (300.4)

• Culture, Age Gender
• Occurs equally in both genders
• Children adolescents will present with symptoms
  of irritability and crankiness
• Course
• Early, insidious onset and chronic course
• May also develop Maj. Dep. D/O
• Those with Maj. Dep. D/O may not have full
  inter-episode recovery from depressed symptoms

19
Dysthymic Disorder (300.4)

• Differential Diagnosis
• Rule out medical condition and substance/medicatio
  n use
• Take a careful history of the clients
  experiences of depression, as this disorder is
  hard to tease apart from Major Depressive
  Disorder
• May also occur with a Personality Disorder. If
  so, both are given.

20
Depressive Disorder NOS (311)

• Exhibits depressive features, but does not meet
  criteria for
• Maj. Dep. D/O
• Dysthymic D/O
• Adj. D/O with Depressed Mood
• Adj. D/O with Mixed Anxiety Depressed Mood
• Or exhibits depressed symptoms about which there
  is inadequate or contradictory information

21
Bipolar I Disorder (296.xx)

• One or more Manic or Mixed episodes, usually
  accompanied by Major Depressive Episodes
• Recurrent episodes are indicated by a shift in
  polarity or interval between episodes of at least
  2 months.

22
Bipolar I Disorder (296.xx)

• Associated features
• High morbidity
• Suicide rates is 10 - 15
• More likely to occur during Depressive or Mixed
  state
• High occurrence of spouse abuse and child abuse
• Other features
• School truancy
• School failure
• Occupational failure
• Divorce
• Episodic antisocial behavior

23
Bipolar I Disorder (296.xx)

• Culture, Age Gender
• No differential in race, age, gender or ethnicity
• Overdiagnosis of Schizophrenia (instead of
  Bipolar) among some ethnic groups

24
Bipolar I Disorder (296.xx)

• Males
• First episode tends to be Manic
• Number of Manic Episodes exceeds number of
  Depressive Episodes
• Females
• First episode tends to be Major Depressive
• Number of Depressive Episodes tends to outnumber
  Manic
• Rapid Cycling is more common in women
• Women with Bipolar I are at increased risk for
  additional episodes post-partum

25
Bipolar I Disorder (296.xx)

• Course
• Age of onset is about 20 years old
• Recurrent chronic
• 90 of those with a Manic Episode will have
  another
• 60 - 70 of Manic Episodes immediately follow a
  Depressive Episode
• Interval between episodes tends to decrease with
  age
• 20 - 30 display mood lability between episodes

26
Bipolar I Disorder (296.xx)

• Familial Pattern
• Strong genetic influence
• Some studies indicate an increased risk of 25 in
  those having one parent with Bipolar D/O, and a
  50 - 75 increased risk in those having both
  parents with Bipolar D/O

27
Bipolar I Disorder (296.xx)

• Differential Diagnosis
• Rule out medical condition and substance/medicatio
  n use, yadda, yadda, yadda
• Look at severity and intensity to differentiate
  from a Hypomanic Episode and Cyclothymic Disorder

28
Bipolar I Disorder (296.xx)

• Schizoaffective Disorder
• There must be a two week period of psychotic
  symptoms outside of a mood episode
• Psychotic D/O
• There may be some symptoms of mania in those with
  these D/O. However, if the criteria are met for a
  Manic or Mixed Episode, the addition diagnosis of
  Bipolar D/O NOS is added.

29
Bipolar I D/OMost recent episode Specifier

• 4th digit
• 296.0x Single Manic Episode
• 296.4x Current or most recent episode is
  Hypomanic or Manic Episode
• 296.5x Current or most recent episode is a
  Depressive Episode
• 296.6x Current or most recent episode is a Mixed
  Episode
• 296.7 Current or most recent episode is
  unspecified (Notice there is no fifth digit for
  this option. Its the only Mood D/O without one).

30
Bipolar I D/OMost recent episode Specifier

• 5th digit
• 296.40 (This one is a bit different).
• Bipolar I Disorder, most recent episode Hypomanic
  AND
• Bipolar I Disorder, most recent episode Manic,
  unspecified

31
Bipolar I D/OSeverity Specifier

• 5th digit
• Clinical status of current (or most recent) mood
• 296.41 Bipolar I Disorder, most recent episode
  Manic, Mild
• 296.42 Bipolar I Disorder, most recent episode
  Manic, Moderate
• 296.43 Bipolar I Disorder, most recent episode
  Manic, Severe, without psychotic features
• 296.44 Bipolar I Disorder, most recent episode
  Manic, Severe, with psychotic features
• 296.45 Bipolar I Disorder, most recent episode
  Manic, in partial remission
• 296.46 Bipolar I Disorder, most recent episode
  Manic, in full remission

32
Major Depressive Bipolar D/OFeatures Specifier

• Catatonic
• Waxy flexibility or stupor
• Excessive motor activity that does not appear to
  be externally influenced
• Rigid posture
• Mutism
• Other peculiarities of voluntary movement
• Echolalia
• Echopraxia

33
Major Depressive Bipolar D/OFeatures Specifier

• Melancholic
• Loss of pleasure in all or almost all activities
• Mood does not improve, even when something good
  happens
• Distinctive depressed mood (different from
  bereavement or feeling sad)
• Depression worse in the morning
• Early morning awakening
• Psychomotor retardation or agitation
• Significant anorexia or weight loss
• Excessive or inappropriate guilt

34
Major Depressive Bipolar D/OFeatures Specifier

• Atypical
• Mood reactivity
• Significant weight gain or increase in appetite
• Hypersomnia
• Leaden paralysis
• Long standing pattern of interpersonal rejection
  sensitivity (pathological sensitivity to being
  rejected by others) resulting in impaired social
  or occupational functioning

35
Major Depressive Bipolar D/OAdditional Course
Specifiers

• Rapid Cycling
• 4 episodes of a Mood Episode in the past 12
  months
• There is a 2 month partial or full remission
  between episodes, or episodes switch to the
  opposite polarity
• Longitudinal
• With full interepisode recovery
• Without full interepisode recovery

36
Major Depressive Bipolar D/OAdditional Course
Specifiers

• Postpartum onset
• Depressive episode which occurs within 4 weeks of
  giving birth
• Seasonal pattern
• There is a regular temporal relationship between
  the onset of the Mood D/O and a particular time
  of year
• Full remission occur in between seasonal episodes
  (or a shift from depression to mania)
• Seasonal episode outnumber non-seasonal episodes

37
Bipolar II Disorder (296.89)

• One or more Major Depressive Episodes,
  accompanied by at least one Hypomanic Episode
• Specifiers
• Hypomanic
• Used if the current or most recent episode is
  Hypomanic
• Depressed
• Used if the current or most recent episode is
  Depressive

38
Bipolar II Disorder (296.89)

• Specifiers
• If the criteria for a Maj. Dep. D/O are met, the
  following additional specifiers may be used
• Mild, moderate, severe without psychotic
  features, severe with psychotic features
• Catatonic, Melancholic, Atypical, Postpartum
  onset
• If the full criteria are not currently met for a
  Hypomanic or Maj. Dep. Episode, the following
  specifiers may be used to describe the current
  clinical state, or the most recent Maj. Dep
  Episode
• Partial remission, full remission
• Catatonic, Melancholic, Atypical, Postpartum
  onset

39
Bipolar II Disorder (296.89)

• Associated features
• High morbidity
• Suicide rates is 10 - 15
• Increased risk for truancy, school failure
  occupational failure and divorce

40
Bipolar II Disorder (296.89)

• Gender features
• More common in women than in men
• Males
• More Hypomanic than Depressive Episodes
• Females
• More Depressive Episodes
• Increased frequency of Rapid Cycling
• Increased risk of developing D/O post-partum

41
Bipolar II Disorder (296.89)

• Course
• 60-70 of the Hypomanic Episodes occur
  immediately after a Maj. Dep. Episode
• Interval between episodes tends to decrease with
  age
• About 15 of those with this D/O continue to
  experience some symptoms in between episodes

42
Bipolar II Disorder (296.89)

• Differential Diagnosis
• Rule out medical condition and substance/medicatio
  n use, yadda, yadda, yadda
• When a person with Maj. Dep. D/O experiences at
  least one Hypomanic Episode, the diagnosis is
  changed to Bipolar II
• Bipolar II is distinguished from Cyclothymia by
  the presence of one or more Maj. Dep D/O
• Schizoaffective Disorder Psychotic D/O
• Psychotic symptoms must be present outside of a
  mood episode

43
Cyclothymic Disorder (301.13)

• 2 years of numerous hypomanic symptoms that do
  not meet the criteria for a Manic Episode, and
  numerous periods of depressive symptoms that do
  not meet the criteria for a Major Depressive
  Episode
• During the 2 years, there can be no Maj. Dep.,
  Manic, or Hypomanic Episodes

44
Cyclothymic Disorder (301.13)

• Age Gender features
• Begins early in life
• Occurs equally in men and women
• Course
• Begins in adolescence or early adulthood
• Insidious onset and chronic course

45
Cyclothymic Disorder (301.13)

• Differential Diagnosis
• One more time, rule out medical condition and
  substance/medication use.
• Specifically, a late onset of Cyclothymia may
  suggest a Mood D/O due to a general medical
  condition
• Distinguished from Bipolar I or II with rapid
  cycling when the mood states do not meet the full
  criteria for a Maj. Dep, Manic or Mixed Episode
• Make sure you consider Borderline Personality
  Disorder, which usually presents with labile and
  variable mood

46
Bipolar Disorder, NOS (296.80)

• Exhibits bipolar features, but does not meet
  criteria for any specific Bipolar Disorder
• Exhibits bipolar symptoms about which there is
  inadequate or contradictory information

47
Mood Disorder due to a (list the General Medical
Condition) (293.83)

• Exhibits prominent and persistent mood
  disturbance that is a direct physiological
  consequence of a General Medical Condition (Code
  condition on Axis III)
• Specifiers include
• With Depressive Features
• With Major Depressive-like Episode
• With Manic Features
• With Mixed Features

48
Substance Induced Mood Disorder 29x.xx (Coding is
dependent on the type of drug used)

• Exhibits prominent and persistent mood
  disturbance that is a direct physiological
  consequence of a drug of abuse, a medication
  another somatic treatment for depression or toxin
  exposure
• Specifiers include
• With Depressive Features
• With Manic Features
• With Mixed Features
• With onset during intoxication
• With onset during withdrawal

49
Mood Disorder NOS (296.90)

• Use for coding disorders with mood symptoms that
  do not meet criteria for any other Mood D/O, and
  for which it is hard to choose between Depressive
  Disorder NOS and Bipolar Disorder, NOS.