diagnosis


As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

The structure of Panic and Agoraphobia Disorders diagnostic criteria in the DSM-IV-TR is similar to that of Mood Disorders; there are the “ingredients” of Panic Attack (which I have quoted below from p. 432 of the DSM-IV-TR) and Agoraphobia (quoted from p. 433), and then the Disorders are like recipes, including or excluding the ingredients in different ways. The Disorders are Panic Disorder Without Agoraphobia (quoted from p. 440), Panic Disorder With Agoraphobia (quoted from p. 441), and Agoraphobia Without History of Panic Disorder (quoted from p. 443).

Please remember that you cannot ethically or accurately diagnose yourself or anyone you know, even if you are a mental health professional. I am posting these criteria for general interest, not diagnosis:
Criteria for Panic Attack

Note: A Panic Attack is not a codable disorder. Code the specific diagnosis in which the Panic Attack occurs (e.g., 300.21 Panic Disorder With Agoraphobia [p. 441]).

A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

(1)    palpitations, pounding heart, or accelerated heart rate

(2)    sweating

(3)    trembling or shaking

(4)    sensations of shortness of breath or smothering

(5)    feeling of choking

(6)    chest pain or discomfort

(7)    nausea or abdominal distress

(8)    feeling dizzy, unsteady, lightheaded, or faint

(9)    derealization (feelings of unreality) or depersonalization (being detached from oneself)

(10)  fear of losing control or going crazy

(11)  fear of dying

(12)  paresthesias (numbness or tingling sensations)

(13)  chills or hot flushes

Criteria for Agoraphobia

Note: Agoraphobia is not a codable disorder. Code the specific diagnosis in which the Panic Attack occurs (e.g., 300.21 Panic Disorder With Agoraphobia [p. 441] or 300.22 Agoraphobia Without History of Panic Disorder [p. 441]).

A.      Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpe3cted or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crows or standing in a line; being on a bridge; and traveling in a bus, train, or automobile.

Note: consider the diagnosis of Specific Phobia if the avoidance is limited to one or only a few specific situations, or social Phobia if the avoidance is limited to social situations.

B.      The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion.

C.      The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as social Phobia (e.g., avoidance limited to a single situation like elevators), Obsessive-Compulsive disorder (e.g., avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving home or relatives).

Diagnostic criteria for 300.01 Panic Disorder Without Agoraphobia

A.      Both (1) and (2):

(1)    recurrent unexpected Panic Attacks (see p. 432)

(2)    at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

(a)    persistent concern about having additional attacks

(b)   worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”)

(c)    a significant change in behavior related to the attacks

B.      The absence of Agoraphobia (see p. 433)

C.      The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

D.      The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety disorder (e.g., in response to being away from home or close relatives).

Diagnostic criteria for 300.21 Panic Disorder With Agoraphobia

A.       Both (1) and (2):

(1)    recurrent unexpected Panic Attacks (see p. 432)

(2)    at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

(a)   persistent concern about having additional attacks

(b)   worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”)

(c)     a significant change in behavior related to the attacks

B.       The presence of Agoraphobia (see p. 433)

C.     The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

D.      The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety disorder (e.g., in response to being away from home or close relatives).

Diagnostic criteria for 300.22 Agoraphobia Without History of Panic Disorder

A.      The presence of Agoraphobia (see p. 433) related to fear of developing panic-like symptoms (e.g., dizziness or diarrhea).

B.      Criteria have never been met for Panic Disorder

C.      The disturbance is not due to the direct physiological effects of a substance (e.g.,  a drug of abuse, a medication) or a general medical condition.

D.      If an associated general medical condition is present, the fear described in Criterion A is clearly in excess of that usually associated with the condition.

Advertisements

As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

The DSM-IV-TR devotes 84 pages to how to diagnose Mood Disorders. It’s a complex business, and something diagnosticians can take extremely seriously. The criteria for the actual disorders (Depressive Disorders and Bipolar Disorders) are like recipes. The ingredients for those recipes are Mood Episodes (Depressive, Manic, Mixed, or Hypomanic) and “specifiers.” The following are the criteria for the specifiers, which are about severity, accompanying symptoms, and timing aspects. The Criteria for Severity/Psychotic/Remission Specifiers for the Mood Episodes are quoted from the DSM-IV-TR:

Major Depressive Episodes, p. 413

Manic Episodes, p. 415

Mixed Episodes, p. 416

Hypomanic Episodes, p. 417

And the criteria for other Mood Disorder specifiers:

Chronic Specifier, p. 417

Catatonic Features Specifier is from p. 418

Melancholic Features Specifier is from p. 420

Atypical Features Specifier is from p. 422

Postpartum Onset Specifier is from p. 423

Criteria for Longitudinal Course Specifier is from p. 425

Seasonal Pattern Specifier is from p. 427

Rapid-Cycling Specifier is from p. 428

Criteria for Severity/Psychotic/Remission Specifiers for current (or most recent) Major Depressive Episodes

Note: Code in fifth digit. Mild, Moderate, Severe Without Psychotic Features, and Severe With Psychotic Features can be applied only if the criteria are currently met for a Major Depressive Episode. In Partial Remission and In Full Remission can be applied to the most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode.

.x1–Mild: Few, if any, symptoms in excess of those required to make the diagnosis and symptoms result in only minor impairment in occupational functioning or in usual social activities or relationships with others.

.x2–Moderate: Symptoms between “mild” and “severe.”

.x3–Severe Without Psychotic Features: Several symptoms in excess of those required to make the diagnosis, and symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others.

.x4–Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:

Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.

Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled.

.x5–In Partial Remission: Symptoms of a Major Depressive Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Major Depressive Episode lasting less than 2 months following the end of the Major Depressive Episode. (If the Major Depressive Episode was superimposed on Dysthymic Disorder, the diagnosis of Dysthymic Disorder alone is given once the full criteria for a Major Depressive Episode are no longer met.)

.x6–In Full Remission: During the past 2 months no significant signs or symptoms of the disturbance were present.

.x0–Unspecified.

 

Criteria for Severity/Psychotic/Remission Specifiers for current (or most recent) Manic Episodes

Note: Code in fifth digit. Mild, Moderate, Severe Without Psychotic Features, and Severe With Psychotic Features can be applied only if the criteria are currently met for a Manic Episode. In Partial Remission and In Full Remission can be applied to the most recent Manic Episode in Bipolar I Disorder only if it is the most recent type of mood episode.

.x1–Mild: Minimum symptoms criteria are met for a Manic Episode

.x2–Moderate: Extreme increase in activity or impairment in judgement.

.x3–Severe Without Psychotic Features: Almost continual supervision required to prevent physical harm to self or others.

.x4–Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:

Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person.

Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical manic themes  of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled.

.x5–In Partial Remission: Symptoms of a Manic Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Manic Episode lasting less than 2 months following the end of the Manic Episode.

.x6–In Full Remission: During the past 2 months no significant signs or symptoms of the disturbance were present.

.x0–Unspecified.

Criteria for Severity/Psychotic/Remission Specifiers for current (or most recent) Mixed Episodes

Note: Code in fifth digit. Mild, Moderate, Severe Without Psychotic Features, and Severe With Psychotic Features can be applied only if the criteria are currently met for a Mixed Episode. In Partial Remission and In Full Remission can be applied to a Mixed Episode  in Bipolar I Disorder only if it is the most recent type of mood episode.

.x1–Mild: No more than minimum symptom criteria are met for both a Manic Episode and a Major Depressive Episode.

.x2–Moderate: Symptoms or functional impairment between “mild” and “severe.”

.x3–Severe Without Psychotic Features: Almost continual supervision required to prevent physical harm to self or others.

.x4–Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:

Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical manic or depressive themes.

Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical manic or depressive themes. of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled.

.x5–In Partial Remission: Symptoms of a Mixed Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Mixed Episode lasting less than 2 months following the end of the Mixed Episode.

.x6–In Full Remission: During the past 2 months no significant signs or symptoms of the disturbance were present.

.x0–Unspecified.

Criteria for Chronic Specifier

Specify if:

Chronic (can be applied to the current or most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode)

Full criteria for a Major Depressive Episode have been met continuously for at least the past 2 years.

Criteria for Catatonic Features Specifier

Specify if:

With Catatonic Features (can be applied to the current or most recent Major Depressive Episode, Manic Episode, or Mixed Episode in Major Depressive Disorder, Bipolar Disorder, or Bipolar II Disorder)

The clinical picture is dominated by at least two of the following:

(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor

(2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli)

(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism

(4) peculiarities of voluntary movements as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

(5) echolalia or echopraxia

Criteria for Melancholic Features Specifier

Specify if:

With Melancholic Features (can be applied to the current or most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode)

A. Either of the following, occurring during the most severe period of the current episode:

(1) loss of pleasure in all, or almost all, activities

(2) lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens)

B. Three (or more) of the following:

(1) distinct quality of depressed mood (i.e., the depressed mood is experienced as distinctly different from the kind of feeling experienced after the death of a loved one)

(2) depression regularly worse in the morning

(3) early morning awakening (at least 2 hours before usual time of awakening)

(4) marked psychomotor retardation or agitation

(5) significant anorexia or weight loss

(6) excessive or inappropriate guilt

Criteria for Atypical Features Specifier

Specify if:

With Atypical Features (can be applied when these features predominate during the most recent 2 weeks of a current Major Depressive Episode in Major Depressive Disorder or in Bipolar I or Bipolar II Disorder when a current Major Depressive Episode is the most recent type of mood episode, or when these features predominate during the most recent 2 years of Dysthymic Disorder; if the Major Depressive Episode is not current, it applies if the feature predominates during any 2-week period)

A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events)

B. Two (or more) of the following features:

(1) significant weight gain or increase in appetite

(2) hypersomnia

(3) leaden paralysis (i.e., heavy, leaden feelings in arms or legs)

(4) long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment

C. Criteria are not met for With Melancholic Features or With Catatonic Features during the same episode.

Criteria for Postpartum Onset Specifier

Specify if:

With Postpartum Onset (can be applied to the current or most recent Major Depressive, Manic, or Mixed Episode in Major Depressive Disorder, Bipolar I Disorder, or Bipolar II Disorder)

Onset of episode within 4 weeks postpartum

Criteria for Longitudinal Course Specifiers

Specify if (can be applied to Recurrent Major Depressive Disorder or Bipolar I or II Disorder):

With Full Interepisode Recovery: if full remission is attained between the two most recent Mood Episodes

Without Full Interepisode Recovery: if full remission is not attained between the two most recent Mood Episodes

Criteria for Seasonal Pattern Specifier

Specify if:

With Seasonal Pattern (can be applied to the pattern of Major Depressive Episodes in Bipolar I disorder, Bipolar II Disorder, or Major Depressive Disorder, Recurrent)

A.      There has been a regular temporal relationship between the onset of Major Depressive Episodes in Bipolar I or Bipolar II Disorder or Major Depressive Disorder, Recurrent, and a particular time of the year (e.g., regular appearance of the Major Depressive Episode in the fall or winter).

Note: Do not include cases in which there is an obvious effect of seasonal related psychosocial stressors (e.g., regularly unemployed every winter).

B.      Full remissions (or a change from depression to mania or hypomania) also occur at a characteristic time of the year (e.g., depression disappears in the spring).

C.      In the last 2 years, two Major Depressive Episodes have occurred that demonstrate the temporal seasonal relationships defined in Criteria A and B, and no nonseasonal Major Depressive Episodes have occurred during that same period.

D.      Seasonal Major Depressive Episodes (as described above) substantially outnumber the nonseasonal Major Depressive episodes that may have occurred over the individual’s lifetime.

Criteria for Rapid-Cycling Specifier

Specify if:

With Rapid Cycling (can be applied to Bipolar I Disorder or Bipolar II Disorder)

At least four episodes of a mood disturbance in the previous 12 months that meet criteria for a Major Depressive, Manic, Mixed, or Hypomanic Episode.

Note: Episodes are demarcated either by partial or full remission for at least 2 months or a switch to an episode of opposite polarity (e.g., Major Depressive Episode to Manic Episode).

As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

I usually post a prevalence-rate map from Wikipedia along with diagnostic criteria. For Bipolar Disorder, though, Wikipedia currently has a map of “age-standardised disability-adjusted life year (DALY) rates.” (Yellow countries have something like two-thirds the DALY rates from Bipolar Disorder of the red countries.)

Bipolar_disorder_world_map_-_DALY_-_WHO2002

DALY is basically trying to measure how costly an affliction is, as opposed to just how many people experience it. Perhaps this is why it looks so much worse in poorer countries than rich ones, quite the opposite of how Major Depressive Disorder prevalence map looks. I’d still like to look at prevalence. Can anyone point me to a good prevalence map?

As you will see, there are a bunch of versions of Bipolar Disorder. The basic ingredients of them are called Mood Episodes (which I have here): Depressive, Manic, Mixed, and Hypomanic Episodes. There are also a whole bunch of “specifiers,” which are used to describe severity, extra features, and timing (which I will link to at some point). The criteria quoted in this post are basically recipes of Episodes and specifiers.

Here are the diagnostic criteria, directly quoted from the DSM-IV-TR, for Bipolar I Disorders (pp. 388-392), Bipolar II Disorder (p. 397),  and Cyclothymic Disorder (p. 400). There is a final Bipolar Disorder Not Otherwise Specified available to diagnosticians who suspect a Bipolar Disorder in a client that doesn’t fit any of the diagnostic criteria. I can’t post criteria for BD NOS, though, because there aren’t any.

Diagnostic criteria for 296.0x Bipolar I Disorder, Single Manic Episode

A. Presence of only one Manic Episode (see p. 362) and no past Major Depressive Episodes.

Note: Recurrence is defined as either a change in polarity from depression or an interval of at least 2 months without manic symptoms.

B. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specify if:

Mixed: if symptoms meet criteria for Mixed Episode (see p. 365)

If the full criteria are currently met for a Manic, Mixed, or Major Depressive Episodespecify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Manic, Mixed, or Major Depressive Episodespecify the current clinical status of the Bipolar I Disorder or features of the most recent episode:

In Partial Remission, In Full Remission (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

Diagnostic criteria for 296.40 Bipolar I Disorder, Most Recent Episode Hypomanic

A. Currently (or most recently) in a Hypomanic Episode (see p. 368).

B. There has previously been at least one Manic Episode (see p. 362) or Mixed Episode (see p. 365).

C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.4x Bipolar I Disorder, Most Recent Episode Manic

A. Currently (or most recently) in a Manic Episode (see p. 362)

B. There has previously been at least one Major Depressive Episode (see p. 356), Manic Episode (see p. 362) or Mixed Episode (see p. 365).

C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If the full criteria are currently met for a Manic Episodespecify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Manic Episodespecify the current clinical status of the Bipolar I Disorder and/or features of the most recent Manic Episode:

In Partial Remission, In Full Remission (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.6x Bipolar I Disorder, Most Recent Episode Mixed

A. Currently (or most recently) in a Mixed Episode (see p. 365).

B. There has previously been at least one Major Depressive Episode (see p. 365), Manic Episode, (see p. 362) or Mixed Episode (see p. 365).

C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If the full criteria are currently met for a Mixed Episodespecify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Mixed Episodespecify the current clinical status of the Bipolar I Disorder and/or features of the most recent Mixed Episode:

In Partial Remission, In Full Remission (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.5x Bipolar I Disorder, Most Recent Episode Depressed

A. Currently (or most recently) in a Major depressive Episode (see p. 365).

B. There has previously been at least one Manic Episode (see p. 362) or Mixed Episode (see p. 365).

C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If the full criteria are currently met for a Major Depressive Episodespecify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Melancholic Features (see p. 419)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Major Depressive Episodespecify the current clinical status of the Bipolar I Disorder and/or features of the most recent Major Depressive Episode:

In Partial Remission, In Full Remission (see p. 414)

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.7 Bipolar I Disorder, Most Recent Episode Unspecified

 A. Criteria, except for duration, are currently (or most recently) met for a Manic (see p. 362), a Hypomanic (see p. 368), a Mixed (see p. 365), or a Major Depressive Episode (see p. 356).

B. There has previously been at least on Manic Episode (see p. 362) or Mixed Episode (see p. 365).

C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

E. The mood symptoms in Criteria A and B are not due to the direct physiological effects of a substance (e.g., a drug of abus, a medication) or a general medical condition (e.g., hypothyroidism).

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 424)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.89 Bipolar II Disorder

A. Presence (or history) of one or more Major Depressive Episodes (seep. 356).

B. Presence (or history) of at least one Hypomanic Episode (see p. 368).

C. There has never been a Manic Episode (see p. 362) or a Mixed Episode (see p. 365).

D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify current or most recent episode:

Hypomanic:  if currently (or most recently) in a Hypomanic Episode (see p. 362)

Depressed:  if currently (or most recently) in a Major Depressive Episode (see p. 356)

If the full criteria are currently met for a Major Depressive Episodespecify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)     Note: Fifth-digit codes specified on p. 413 cannot be used here because the code for Bipolar II Disorder already uses the fifth digit.

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Melancholic Features (see p. 419)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Hypomanic or Major Depressive Episodespecify the current clinical status of the Bipolar II Disorder and/or features of the most recent Major Depressive Episode (only if it is the most recent type of mood episode):

In Partial Remission, In Full Remission (see p. 414)     Note: Fifth-digit codes specified on p. 413 cannot be used here because the code for Bipolar II Disorder already uses the fifth digit.

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Melancholic Features (see p. 419)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 301.13 Cyclothymic Disorder

A. For at least 2 years, the presence of numerous periods with hypomanic symptoms (see p. 368) and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode.     Note: In children and adolescents, the duration must be at least 1 year.

B. During the above 2-year period (1 year in children and adolescents), the person has not been without the symptoms in Criterion A for more than 2 months at a time.

C. No Major Depressive Episode (p. 356), Manic Episode (p. 362), or Mixed Episode (see p. 365) has been present during the first 2 years of the disturbance.

Note: After the initial 2 years (1 year in children and adolescents) of Cyclothymic Disorder, there may be superimposed Manic or Mixed Episodes (in which case both Bipolar I Disorder and Cyclothymic Disorders may be diagnosed) or Major Depressive Episodes (in which case both Bipolar II Disorder and Cyclothymic Disorder may be diagnosed).

D. The symptoms in Criterion A are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

Major Depressive Disorder is one of the most common diagnoses given in the mental health field, almost 15 million adults at a time in the US, according to NIHM. The DSM-IV-TR says that it occurs equally throughout ethnicities, education and income strata, and for married and unmarried people. It does not occur equally by gender, however, with something like three times as many women as men carrying the diagnosis. It’s also not spread equally by nationality. Here’s a Wikipedia map of the distribution. The red countries have twice as much Major Depressive Disorder:

800px-Unipolar_depressive_disorders_world_map_-_DALY_-_WHO2004

Here are the diagnostic criteria for Major Depressive Disorder, first Single Episode then Recurrent, word for word quoted from the DSM-IV-TR, pages 375 and 376. Note that most of the diagnostic action happens in the criteria for Major Depressive Episode, not Major Depressive Disorder. Also, it is interesting (and frustrating, in my case) that most prescribers and a great many diagnosticians use Major Depressive Episode’s criteria A and B, but disregard criteria C, D and E. That is, the symptom lists are considered important but the disqualification by environmental and historical factors are not.

Diagnostic criteria for 296.2x Major Depressive Disorder, Single Episode

A.      Presence of a single Major Depressive Episode (see p. 356)

B.      The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophreniform disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C.      There has never been a Manic Episode (see p. 362), a Mixed Episode (see p. 365), or a Hypomanic Episode (see p. 368). Note:   This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects  of a general medical condition.

If the full criteria are currently met for a Major Depressive Episodespecify its current clinical status and/or features:

Mild Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a  Major Depressive Episode, specify the current clinical status of the Major Depressive Disorder or features of the most recent episode:

In Partial Remission, In Full Remission (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

Diagnostic criteria for 296.3x Major Depressive Disorder, Recurrent

A.      Presence of two or more Major Depressive Episodes (see p. 356)

Note: To be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are not met for a Major Depressive Episode.

B.      The Major Depressive Episodes are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizzophreniform disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C.      There has never been a Manic Episode (see p. 362), a Mixed Episode (see p. 365), or a Hypomanic Episode (see p. 368). Note:   This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects  of a general medical condition.

If the full criteria are currently met for a Major Depressive Episodespecify its current clinical status and/or features:

Mild Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a  Major Depressive Episodespecify the current clinical status of the Major Depressive Disorder or features of the most recent episode:

In Partial Remission, In Full Remission (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

The Diagnostic and Statistical Manual of Mental Disorders is a giant catalog of behaviors and other complaints that cause people to suffer psychologically. If a person claims or admits to having a constellation of problems which fits one of the categories in the DSM, they can be diagnosed with that Mental Disorder. Most people who make these diagnoses as part of their living take this process very seriously, distinguishing between subtypes of ADHD in a client with the same seriousness as a doctor distinguishing between subtypes of breast cancer in a patient. This book has the answers. It is like the Bible for mental health diagnosticians.

Every decade or so, we get a new version of our Bible. Here are the six versions we’ve had since 1958.

DSMs

We are about to get a new version this spring. This change-over is both exciting and awkward in a way that I don’t imagine new versions of other Bibles can be. When a new version of the Christian Bible come out, I imagine that the impact is mostly academic, and the new version may or may not catch on. With a new DSM, there is no choice for diagnosticians or their clients. In 1973, you could diagnose someone with Homosexuality Disorder. In 1975, you could not. The debate was over.

More often than disappearing, new disorders become available. Asperger’s Disorder, for example, appeared in version IV, in 1994. At other times the categories change in big ways, such as the much-talked-about removal of Asperger’s Disorder in the upcoming version V in favor of a more inclusive “Autism Spectrum.”

The awkwardness of this process is especially salient to me, just starting my internship as a family therapist. Since I live in California, I must do my 3,000 client-contact hours for licensure at a community clinic, which means I have to diagnose each of my clients with a qualifying Mental Disorder. To that end, I have been boning up on my diagnostic criteria in the DSM-IV-TRI have to be really good at this to get the resources flowing for my clients. At the same time, I am aware that in a matter of weeks I will be learning not only new criteria and new Mental Disorders, but a whole new diagnostic process spelled out in the DSM-V.

I read Whitaker’s Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America as a counterpoint assignment in one of the diagnosis classes in my Couples & Family Therapy program. It was an excellent book about the history and science of several psychological problems, both as phenomena and diagnoses, including depression, depression, bipolar disorder, ADHD, and schizophrenia. As a university student, I had the opportunity to check out for free any of the many academic citations in the book that piqued my interest, and each one that I looked at seemed indeed to provide the evidence he claimed. I haven’t read anything like all of them (there are nearly 700), but enough to satisfy myself that Whitaker has done some good journalism here, and that his hypotheses are credible.

Two of these hypotheses is about childhood bipolar disorder, the first of which he calls the “ADHD to bipolar pathway.” The side effects of stimulants such as those used to treat ADHD are substantially similar to bipolar symptoms, as shown in the table below, from p. 238. (The formatting is slightly different than Whitaker’s, thanks to an Open Office/Wordpress interaction.) Multiplying the estimated rate of stimulant-induced bipolar-like symptoms by the 3,500,000 children and teens taking those medications, Whitaker estimates we should see approximately 400,000 “bipolar youth” as a result.

The ADHD to Bipolar Pathway

Stimulant-Induced Symptoms

Bipolar Symptoms

Arousal

Dysphoric

Arousal

Dysphoric

Increased lethargy

Intensified focus

Hyperalertness

Euphoria

Agitation, anxiety

Insomnia

Irritability

Hostility

Hypomania

Mania

Psychosis

Somnolence

Fatigue, lethargy

Social withdrawal, isolation

Decreased spontaneity

Reduced curiosity

Constriction of affect

Depression

Emotional lability

Increased energy

Intensified goal-directed activity

Decreased need for sleep

Severe mood change

Irritability

Agitation

Destructive outbursts

Increased talking

Hypomania

Mania

Sad mood

Loss of energy

Loss of interest in activities

Social isolation

Poor communication

Feelings of worthlessness

Unexplained crying

The second part of Whitaker’s thinking on childhood bipolar disorder is an SSRI to bipolar pathway. Estimates of the rate of the well-know SSRI side effect of mania, multiplied by 2,000,000 children and adolescents on the medications, give us the possibility of producing at least 500,000 SSRI-induced bipolar disorders in young people.

If true, these hypotheses could go a long way to explain the skyrocketing rates of childhood bipolar disorder diagnoses, as most diagnoses of childhood bipolar disorder are made on children who are already taking stimulants and/or SSRIs. The primary alternative, and more mainstream, hypothesis is not that stimulants and SSRIs are iatrogenic, but that since those medications solve the problems of ADHD and depression, the symptoms of bipolar disorder that emerge show that the diagnostician had initially guessed wrong, and that bipolar disorder was the previously-existing and underlying cause of the ADHD and/or depression. This, of course, may be true, but it seems very important to discover for certain whether it is!

PTSD was recognized in the early 1970s and formalized in 1980, largely the result of work by and with US veterans of the war in Vietnam. Many people who think about these things consider this recognition to be a turning point in psychological diagnosis. In fact, one way of thinking about psychological diagnosis is that most of what we now call Mental Disorders are basically variants of PTSD–the ways that different people respond to different traumas. If the committee working on version V of the DSM were to humor us, they might rename the tome The North American and European Catalog of Post-Traumatic Stress Behavior Patterns Plus a Few Other Human Difficulties.

Here’s a fuzzy map from the wikipedia article, showing PTSD rates. The darker the red, the more PTSD, and the lighter the yellow, the less:

Here are the criteria, word for word, from the Diagnostic and Statistical Manual of Mental Disorders IV-TR, pages 467 and 468:

Diagnostic criteria for 309.81 Posttraumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

(2) the person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior

B. The traumatic event is persistently reexperienced in one (or more) of the following ways:

(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.

(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or More ) of the following:

(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma

(2) efforts to avoid activities, places, or people that arouse recollections of the trauma

(3) inability to recall an important aspect of the trauma

(4) markedly diminished interest or participation in significant activities

(5) feeling of detachment or estrangement from others

(6) restricted range of affect (e.g., unable to have loving feelings)

(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before trauma), as indicated by two (or more) of the following:

(1) difficulty falling or staying asleep

(2) irritability or outbursts of anger

(3) difficulty concentrating

(4) hypervigilance

(5) exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F. The distrubance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

Acute: if duration of symptoms is less than 3 months

Chronic: if duration of symptoms is 3 months or more

Specify if:

With Delayed Onset: if onset of symptoms is at least 6 months after the stressor

Next Page »