Comprehensive Mood Disorders Notes (DSM-5-TR)

DSM-5-TR Changes in Mood Disorder Classification

  • Mood disorders are disorders with a disturbance in mood as the predominant feature; they include depressive disorders and bipolar and related disorders.

  • DSM-5-TR introduced several wording changes and diagnostic codes related to mood disorders:

    • Bipolar and related disorders due to another medical condition were reworded to include terms like “substance/medication-induced bipolar and related disorder” and “depressive disorder due to another medical condition.”
    • For Bipolar I and Bipolar II, mood disorder diagnoses can be made when the basic episode criteria are met and mood episodes cannot be fully explained by the criteria for another psychotic disorder in which mood episodes are not part of the diagnosis (i.e., mood episodes should not be explained away by another condition).
    • Addition of diagnostic codes for suicidal behavior and nonsuicidal self-injury.

  • Unspecified Mood Disorder and Persistent Depressive Disorder (dysthymia) wording changes in DSM-5-TR:

    • Unspecified Mood Disorder applies when depressive symptoms predominate and cause clinically significant distress or impairment, but there is insufficient information to specify a depressive disorder (e.g., emergency settings).
    • Persistent Depressive Disorder (PDD) no longer uses the parenthetical term “dysthymia” as a separate label; the term is simplified in the DSM-5-TR framework.

  • Core depressive and bipolar presentations highlighted, including:

    • Disruptive Mood Dysregulation Disorder (DMDD)
    • Major Depressive Disorder (MDD)
    • Persistent Depressive Disorder (PDD)
    • Premenstrual Dysphoric Disorder (PMDD)

Major Depressive Disorder (MDD)

  • Clinical description

    • Bereavement exclusion: bereaved individuals were historically excluded from MDD, but DSM-5-TR emphasizes distinguishing normal grief from a major depressive episode. Melancholy in grief is often accompanied by thoughts of the deceased; however, MDE is pervasive and persistent beyond a normal grief response.
    • Normal sadness and grief vs. MDD should be carefully delineated.
    • In children/adolescents, mood can be irritable rather than sad, which requires consideration in diagnosis.

  • Diagnostic criteria for a Major Depressive Episode (MDE)

    • A. Five (or more) of the following symptoms have been present during the same 2-\text{week} period and represent a change from previous functioning; at least one of the symptoms is (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms clearly attributable to another medical condition.
    1. Depressed mood most of the day, nearly every day, as indicated by subjective report or observation; in children/adolescents, irritable mood may be present.
    2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
    3. Significant weight loss when not dieting or weight gain, or decrease/increase in appetite nearly every day (in children, consider failure to gain weight).
    4. Insomnia or hypersomnia nearly every day.
    5. Psychomotor agitation or retardation nearly every day.
    6. Fatigue or loss of energy nearly every day.
    7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
    8. Diminished ability to think or concentrate, indecisiveness nearly every day.
    9. Recurrent thoughts of death, suicidal ideation, or a suicide attempt or plan.
    • B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • C. The episode is not attributable to the physiological effects of a substance or another medical condition.
    • D. The episode is not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified/unspecified schizophrenia spectrum and other psychotic disorders.
    • E. There has never been a manic episode or a hypomanic episode.
    • Note: This exclusion does not apply if manic-like or hypomanic-like episodes are substance-induced or attributable to another medical condition.

  • Coding and recording procedures (examples)

    • Coding is based on single vs recurrent episode, current severity, presence of psychotic features, and remission status:
    • Single episode vs Recurrent episode
    • Severity: Mild F32.0, F33.0; Moderate F32.1, F33.1; Severe F32.2, F33.2; With psychotic features F32.3, F33.3; In partial remission F32.4, F33.41; In full remission F32.5, F33.42; Unspecified F32.9, F33.9.
    • A recurrent episode requires an interval of at least 2\text{ consecutive months} with criteria not met for a MDE.
    • Specifiers (examples): with anxious distress, with mixed features, with melancholic features, with atypical features, with mood-congruent/ mood-incongruent psychotic features, with catatonia, with peripartum onset, with seasonal pattern.

Differential Diagnosis for MDD

  • AD/HD: Can be diagnosed in addition to MDD but mood symptoms in children with AD/HD may reflect irritability rather than sadness or anhedonia.
  • Adjustment Disorder with depressed mood: Full MDE criteria not met.
  • Bereavement: Grief-related sadness; not always MDD, but a major depressive episode can co-occur based on clinical judgment.
  • Sadness: Normal human sadness; not a depressive disorder unless criteria for severity, duration, and impairment are met.

Persistent Depressive Disorder (PDD/Dysthymia)

  • Description

    • A milder, chronic form of depression with depressive experiences lasting for at least 2\text{ years} (at least 1\text{ year} in children/adolescents), with two or more milder depressive symptoms.
    • Non-episodic, chronic depressive symptoms with lower severity than MDD.

  • Distinguishing features

    • Symptom burden persistent over time, not meeting full criteria for an MDE.

Disruptive Mood Dysregulation Disorder (DMDD)

  • Core features

    • Recurrent temper outbursts that are grossly out of proportion in intensity/duration to the situation.
    • Outbursts occur at least 3\text{ times per week} for at least 12\text{ months}, across at least two settings (e.g., home, school, with peers).
    • Persistent irritable or angry mood between outbursts most of the day, nearly every day.
    • Onset between ages 6\text{ and }18 years; criteria not met before age 6 or after age 18; onset typically before age 10.

  • Important diagnostic notes

    • Do not diagnose DMDD if the individual has ever had a manic or hypomanic episode.
    • If criteria are met for both DMDD and another disorder (e.g., ODD or IED), clinicians may diagnose DMDD; otherwise, DMDD should be diagnosed when criteria are met and other disorders are ruled out.
    • DMDD cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder; it may co-occur with MDD, ADHD, conduct disorder, or substance use disorders in some cases.

  • DSM-5-TR criteria (summary)

    • A through I outline the duration, settings, and age limitations; ensure the absence of manic symptoms; ensure symptoms are not attributable to substances or another medical condition.

Premenstrual Dysphoric Disorder (PMDD)

  • Characterized by depressive symptoms in the final week before menses and during menses, with functional impairment.

  • Diagnostic criteria (summary):

    • A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before menses, start to improve within a few days after onset of menses, and become minimal or absent in the week postmenses (PMDD requires robust cyclic pattern). \text{Must meet A}.
    • B. One or more of the following symptoms must be present: (1) Marked affective lability; (2) Marked irritability or anger; (3) Marked depressed mood or hopelessness; (4) Marked anxiety or tension.
    • C. One or more of the following additional symptoms must be present to reach a total of five when combined with Criterion B: (1) Decreased interest in usual activities; (2) Difficulties in concentration; (3) Lethargy or fatigue; (4) Marked change in appetite; (5) Hypersomnia or insomnia; (6) Sense of being overwhelmed; (7) Physical symptoms such as breast tenderness or swelling, joint or muscle pain, bloating, or weight gain.
    • D. Symptoms cause clinically significant distress or impairment.
    • E. Not attributable to another disorder (e.g., MDD, panic disorder) but may co-occur.
    • F. Prospective daily ratings during at least two symptomatic cycles to confirm.
    • G. Not attributable to substances or another medical condition.

  • Note: Symptoms must have occurred for most cycles in the preceding year.

Bipolar and Related Disorders

  • Bipolar I Disorder

    • Characterized by fluctuations between high and low moods; at least one manic episode in lifetime.
    • Manic Episode criteria (DSM-5-TR):
    • A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally increased goal-directed activity or energy, lasting at least 1\text{ week} (or any duration if hospitalization is required) and present most of the day, nearly every day.
    • B. During the period, at least 3\text{ (or more) }$ signs or symptoms were present (or 4 if mood is only irritable) including: inflated self-esteem or grandiosity; decreased need for sleep; more talkative than usual; flight of ideas or subjective experience that thoughts are racing; distractibility; increase in goal-directed activity or psychomotor agitation; excessive involvement in activities with high potential for painful consequences.
    • C. The mood disturbance is sufficiently severe to cause marked impairment, or to require hospitalization, or there are psychotic features.
    • D. Not attributable to the physiological effects of a substance or another medical condition.

  • Bipolar I: additional notes

    • Mood episodes may be preceded by and followed by hypomanic or major depressive episodes.

  • Bipolar II Disorder

    • Involves at least one hypomanic episode and at least one major depressive episode; never a manic episode.
    • Hypomanic episode criteria (DSM-5-TR) similar to mania but with (i) shorter duration (minimum 4\text{ days}), (ii) not severe enough to cause marked impairment or hospitalization, and (iii) no psychotic features.
    • Major depressive episodes must also be present; the cycling between hypomania and depression causes clinically significant distress or impairment.
    • Distinguishing factors from Bipolar I: absence of a full manic episode.

  • Cyclothymic Disorder

    • A milder, chronic form of bipolar spectrum disorder.
    • Criteria: for at least 2\text{ years} (1\text{ year} in children/adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.
    • Symptoms present at least half the time and have not been without symptoms for more than 2\text{ months} at a time during the above period.
    • Criteria for a major depressive, manic, or hypomanic episode have never been met.
    • Not attributable to substances or another medical condition.
    • Clinically significant distress or impairment.
    • Specify if: with anxious distress.

  • Other diagnostic considerations for Bipolar spectrum

    • Rapid cycling: a specifier that can apply to Bipolar I or II when there are at least four mood episodes (depressive, manic, hypomanic, or mixed) within a 12-month period in which symptoms meet full criteria.
    • Differential diagnoses include borderline personality disorder; if criteria are met for both disorders, consider the possibility of comorbidity but assess carefully for symptom overlap and functional impairment.

Etiology of Mood Disorders

  • Biological factors

    • Neurotransmitter alterations (e.g., serotonin-5-HT and its presynaptic activity; postsynaptic serotonin receptor functioning).
    • Dysregulation of the HPA axis (hypothalamic-pituitary-adrenal axis) and stress response.
    • Amygdala hyperactivity and heightened cortisol at night (especially in adolescents) increasing depression risk.
    • Low levels of serotonin and oxytocin associated with depressive symptoms.

  • Sociocultural factors

    • Perinatal insults; early childhood relationships; parenting styles; reinforcement of gender roles.
    • Parental presence/absence, poverty, exposure to traumatic life events, violence, death, legal problems, or unwanted sexual contact.
    • Close friendships can sometimes increase risk of depressive symptoms when stressors arise.

  • Psychological factors

    • Beck’s cognitive model: negative beliefs about self, world, and others; negative schema dominate perception.
    • Diathesis-stress framework: vulnerability plus stress leads to depression.
    • Rumination and cognitive biases toward negative information.

Interventions and Management

  • Psychotherapy

    • Cognitive-behavioral therapy (CBT): teaches skills to prevent recurrence by changing maladaptive cognitions.
    • Interpersonal psychotherapy (IPT): improves interpersonal functioning and relationships.
    • CBT and IPT often recommended in combination with pharmacotherapy.
    • Psychodynamic therapy (PDP): explores unconscious processes, early experiences, transference, countertransference, and resistance.
    • Mindfulness-based cognitive therapy (MBCT): helps disrupt automatic depressive patterns; integrates meditation, mindful movement, and cognitive strategies.

  • Self-care and lifestyle interventions

    • Exercise, meditation and breathing exercises, morning rituals, hobbies, and mindful activities.
    • Proper diet and nutrition; avoid drugs and alcohol; emphasize social support.
    • Regular sleep patterns and stress management to reduce recurrence risk.

  • Pharmacotherapy

    • Antidepressants: diverse options including tricyclics, SSRIs, and newer atypical agents.
    • Maintenance strategy: continue medications for 6\text{ to }9\text{ months} beyond symptom remission to prevent relapse; full-dose maintenance may be indicated for high-risk individuals.

Other Specified and Unspecified Mood Disorders

  • Other Specified Mood Disorder

    • Presentations with mood-related distress/impairment that do not meet full criteria for any specific mood disorder.
    • Clinician documents the specific reason (e.g., non-specific short-duration depressive episode).
    • Examples often include: recurrent brief depression, depressive episodes with insufficient symptoms, mood episodes superimposed on another disorder.

  • Unspecified Mood Disorder

    • Used when clinician chooses not to specify the exact reason criteria are not met for a mood disorder.
    • Helpful in acute settings where further information is not yet available.

  • Unspecified mood disorder coding

    • Useful when diagnostic clarity between bipolar vs depressive disorder is uncertain at evaluation time.

Diagnostic Summary and Visual Aids

  • Mood disorder states and timelines (illustrative relationships):
    • Euthymic ⇄ Depressed (Major Depressive Episode) ⇄ Hypomania ⇄ Mania ⇄ Cyclothymia (2 years) ⇄ Bipolar I ⇄ Bipolar II.
    • Key durations: manic episodes require at least 1\text{ week} (or hospitalization), hypomanic episodes require at least 4\text{ days}, depressive episodes vary but often last weeks to months.

Case Discussion and Review Questions

  • Case-based prompts include:
    • Precipitating factors influencing diagnosis (e.g., mood symptoms, functional impairment, risk factors).
    • Possible treatment and management actions for similar cases.
    • Identification of signs and symptoms that meet DSM-5-TR criteria for Major Depressive Disorder in given cases.

Quick Reference: Specifiers and Codes (MDD)

  • Specifiers to consider with MDD (examples): with anxious distress, with mixed features, with melancholic features, with atypical features, with mood-congruent psychotic features, with mood-incongruent psychotic features, with catatonia, with peripartum onset, with seasonal pattern.
  • Example codes (recording order): major depressive disorder, single or recurrent episode, severity/psychotic/remission specifiers, followed by additional applicable specifiers (without codes) such as with seasonal pattern.

Quick Reference: PMDD Diagnostic Codes and Criteria

  • PMDD code example: F32.81$$ (for coding in relation to DSM-5-TR implementations).
  • Summary of criteria re-emphasized above under PMDD section.

Notes on DSM-5-TR and Clinical Practice

  • DSM-5-TR updates emphasize precise definitions for mood disorders, refined specifiers, and clearer differentiation from grief, adjustment disorders, and other psychiatric conditions.
  • Clinicians should use clinical judgment to differentiate normal emotional responses (grief, sadness, irritability) from clinically significant depressive or bipolar disorders, particularly in pediatric populations and during life events.