Bipolar and Related Disorder Due to Another Medical Condition 145
This condition follows the ingestion or inhalati on quickly, usually within hours or, at the
most, a few days. In stimulant-induced manic or  hypomanic states, the response is in min-
utes to 1 hour after one or several ingestions  or injections. The episode is very brief and
typically resolves over 1–2 days. With co rticosteroids and some immunosuppressant
medications, the mania (or mixed or depressed state) usually follows several days of in-
gestion, and the higher doses appear to have a much greate r likelihood of producing bi-
polar symptoms.
Diagnostic Markers
Determination of the substance of use can be made through markers in the blood or urine
to corroborate diagnosis.
Differential Diagnosis
Substance/medication-induced bipolar and related disorder should be differentiated
from other bipolar disorders, substance into xication or substance-induced delirium, and
medication side effects (as noted earlier). A full manic episode that emerges during anti-
depressant treatment (e.g., medication, electr oconvulsive therapy) but persists at a fully
syndromal level beyond the physiological effect of that treatment is sufficient evidence for
a bipolar I diagnosis. A full hypomanic episode  that emerges during antidepressant treat-
ment (e.g., medication, electroconvulsive therap y) but persists at a fully syndromal level
beyond the physiological effect of that treatme nt is sufficient evidence for a bipolar II di-
agnosis only if preceded by a major depressive episode.
Comorbidity
Comorbidities are those associated with the use of illicit substances (in the case of illegal
stimulants or phencyclidine) or diversion of prescribed stimulants. Comorbidities related


to steroid or immunosuppre ssant medications are those medical indications for these
preparations. Delirium can occur before or along with manic symptoms in individuals in-
gesting phencyclidine or those who are prescr ibed steroid medications or other immuno-
suppressant medications.
Bipolar and Related Disorder
 Due to Another Medical Condition
Diagnostic Criteria
A. A prominent and persistent period of abnormall y elevated, expansive, or irritable mood
and abnormally increased activity or energy that predominates in the clinical picture.
B. There is evidence from the history, physical ex amination, or laboratory findings that the dis-
turbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioni ng, or necessitates hospitalization to pre-
vent harm to self or others, or there are psychotic features.
Coding note:  The ICD-9-CM code for bipolar and related disorder due to another medical
condition is 293.83, which is assigned regardless of the specifier. The ICD-10-CM code
depends on the specifier (see below).


146 Bipolar and Related Disorders
Specify if:
(F06.33) With manic features:  Full criteria are not met for a manic or hypomanic ep-
isode.
(F06.33) With manic- or hypomanic-like episode:  Full criteria are met except Crite-
rion D for a manic episode or except Criterion F for a hypomanic episode.
(F06.34) With mixed features:  Symptoms of depression are also present but do not
predominate in the clinical picture.
Coding note: Include the name of the other medical condition in the name of the mental
disorder (e.g., 293.83 [F06.33] bipolar disorder due to hyperthyroidism, with manic fea-
tures). The other medical condition should also be coded and listed separately immedi-
ately before the bipolar and related disorder due to the medical condition (e.g., 242.90
[E05.90] hyperthyroidism; 293.83 [F06.33] bipol ar disorder due to hyperthyroidism, with
manic features).
Diagnostic Features
The essential features of bipolar and related disorder due to anothe r medical condition are
presence of a prominent and persistent period of abnormally elevated, expansive, or irri-
table mood and abnormally increased activity or energy predominating in the clinical pic-
ture that is attributable to another medical condition (Criterion B). In most cases the manic
or hypomanic picture may appear during the in itial presentation of the medical condition
(i.e., within 1 month); howeve r, there are exceptions, especi ally in chronic medical condi-
tions that might worsen or relapse and herald  the appearance of the manic or hypomanic
picture. Bipolar and related disorder due to another medical condition would not be diag-


picture. Bipolar and related disorder due to another medical condition would not be diag-
nosed when the manic or hypomanic episodes definitely preceded the medical condition,
since the proper diagnosis would be bipolar disorder (except in the unusual circumstance
in which all preceding manic or hypomanic episodes—or, when only one such episode has
occurred, the preceding manic or hypomanic episode—were associated with ingestion of
a substance/medication). The diagnosis of bipolar and related disorder due to another
medical condition should not be made during the course of a delirium (Criterion D). The
manic or hypomanic episode in  bipolar and related disorder due to another medical con-
dition must cause clinically significant dist ress or impairment in social, occupational, or
other important areas of fu nctioning to qualify for this diagnosis (Criterion E).
Associated Features Supporting Diagnosis
Etiology (i.e., a causal relationship to anothe r medical condition based on best clinical ev-
idence) is the key variable in this etiologically  specified form of bipolar disorder. The list-
ing of medical conditions that are said to be able to induce mania is never complete, and
the clinician’s best judgment is the essence of  this diagnosis. Among the best known of the
medical conditions that can cause a bipolar manic or hypomanic co ndition are Cushing’s
disease and multiple sclerosis, as well as stroke and traumatic brain injuries.
Development and Course
Bipolar and related disorder due to another me dical condition usually has its onset acutely
or subacutely within the firs t weeks or month of the onset of the associated medical con-
dition. However, this is not always the case, as a worsening or later relapse of the associ-
ated medical condition may precede the onset of the manic or hypomanic syndrome. The


ated medical condition may precede the onset of the manic or hypomanic syndrome. The
clinician must make a clinical judgment in these situations about whether the medical con-
dition is causative, based on temporal sequence  as well as plausibility of a causal relation-


Bipolar and Related Disorder Due to Another Medical Condition 147
ship. Finally, the condition may remit before or just after the medi cal condition remits,
particularly when treatment of the ma nic/hypomanic symptoms is effective.
Culture-Related Diagnostic Issues
Culture-related differences, to the extent that  there is any evidence, pertain to those asso-
ciated with the medical condition (e.g., rates of multiple sclerosis and stroke vary around
the world based on dietary, genetic fact ors, and other environmental factors).
Gender-Related Diagnostic Issues
Gender differences pertain to those associat ed with the medical condition (e.g., systemic
lupus erythematosus is more common in fema les; stroke is somewhat more common in
middle-age males compared with females).
Diagnostic Markers
Diagnostic markers pertain to those associated with the medical condition (e.g., steroid
levels in blood or urine to help corroborate the diagnosis of Cushing’s disease, which can
be associated with manic or depressive synd romes; laboratory test s confirming the diag-
nosis of multiple sclerosis).
Functional Consequences of Bipolar and Related
Disorder Due to Anot her Medical Condition
Functional consequences of the bipolar sy mptoms may exacerbate impairments associ-
ated with the medical condit ion and may incur worse outcom es due to interference with
medical treatment. In general, it is believed, but not established, that the illness, when in-
duced by Cushing’s disease, will not recur if the Cushing’s disease is cured or arrested.
However, it is also suggested, but not establ ished, that mood syndromes, including de-
pressive and manic/hypomanic ones, may be episod ic (i.e., recurring) with static brain in-
juries and other central nervous system diseases.
Differential Diagnosis


juries and other central nervous system diseases.
Differential Diagnosis
Symptoms of delirium, catatonia, and acute anxiety. It is important to differentiate
symptoms of mania from excite d or hypervigilant delirious symptoms; from excited cata-
tonic symptoms; and from agitation related to acute anxiety states.
Medication-induced depre ssive or manic symptoms. An important differential diag-
nostic observation is that the other medica l condition may be treated with medications
(e.g., steroids or alpha-interferon) that can induce depressive or manic symptoms. In these
cases, clinical judgment using all of the eviden ce in hand is the best way to try to separate
the most likely and/or the most important of two etiological factors (i.e., association with
the medical condition vs. a substance/medicati on-induced syndrome). The differential di-
agnosis of the associated medical conditions is relevant but largely beyond the scope of the
present manual.
Comorbidity
Conditions comorbid with bipolar and relate d disorder due to anot her medical condition
are those associated with the medical conditio ns of etiological relevance. Delirium can oc-
cur before or along with manic symptoms in individuals with Cushing’s disease.


148 Bipolar and Related Disorders
Other Specified Bipolar and Related Disorder
296.89 (F31.89)
This category applies to presentations in which symptoms characteristic of a bipolar and
related disorder that cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning predominate but do not meet the full criteria
for any of the disorders in the bipolar and related disorders diagnostic class. The other
specified bipolar and related disorder category is used in situations in which the clinician
chooses to communicate the specific reason that the presentation does not meet the cri-
teria for any specific bipolar and related disorder. This is done by recording “other speci-
fied bipolar and related disorder” followed by the specific reason (e.g., “short-duration
cyclothymia”).
Examples of presentations that can be specified using the “other specified” designation
include the following:
1.Short-duration hypomanic episodes (2–3 days) and ma jor depressive episodes:  A
lifetime history of one or more major depressive episodes in individuals whose presenta-
tion has never met full criteria for a manic or hypomanic episode but who have experienced
two or more episodes of short-duration hypoma nia that meet the full symptomatic criteria
for a hypomanic episode but that only last for 2–3 days. The episodes of hypomanic symp-
toms do not overlap in time with the major depressive episodes, so the disturbance does
not meet criteria for major depressive episode, with mixed features.
2.Hypomanic episodes with insufficient  symptoms and major depressive epi-
sodes: A lifetime history of one or more major depressive episodes in individuals
whose presentation has never met full criteria for a manic or hypomanic episode but
who have experienced one or more episodes of hypomania that do not meet full symp-


who have experienced one or more episodes of hypomania that do not meet full symp-
tomatic criteria (i.e., at least 4 consecutive days of elevated mood and one or two of
the other symptoms of a hypomanic episode, or irritable mood and two or three of the
other symptoms of a hypomanic episode). The episodes of hypomanic symptoms do
not overlap in time with the major depressive episodes, so the disturbance does not
meet criteria for major depressive episode, with mixed features.
3.Hypomanic episode without pr ior major depressive episode:  One or more hypo-
manic episodes in an individual whose presentation has never met full criteria for a ma-
jor depressive episode or a manic episode. If this occurs in an individual with an
established diagnosis of persistent depressive disorder (dysthymia), both diagnoses
can be concurrently applied during the periods  when the full criteria for a hypomanic
episode are met.
4.Short-duration cyclothymia (less than 24 months):  Multiple episodes of hypomanic
symptoms that do not meet criteria for a hypomanic episode and multiple episodes of de-
pressive symptoms that do not meet criteria for a major depressive episode that persist
over a period of less than 24 months (less than 12 months for children or adolescents)
in an individual whose presen tation has never met full criteria for a major depressive,
manic, or hypomanic episode and does not meet criteria for any psychotic disorder. Dur-
ing the course of the disorder, the hypomanic or depressive symptoms are present for
more days than not, the individual has not been without symptoms for more than 2 months
at a time, and the symptoms cause clinically significant distress or impairment.


Unspecified Bipolar and Related Disorder 149
Unspecified Bipolar and Related Disorder
296.80 (F31.9)
This category applies to presentations in which symptoms characteristic of a bipolar and
related disorder that cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning predominate but do not meet the full criteria
for any of the disorders in the bipolar and related disorders diagnostic class. The unspec-
ified bipolar and related disorder category is used in situations in which the clinician choos-
es not to specify the reason that the criteria are not met for a specific bipolar and related
disorder, and includes presentations in which there is insufficient information to make a
more specific diagnosis (e.g., in emergency room settings).
Specifiers for Bipolar and Related Disorders
Specify if:
With anxious distress:  The presence of at least two of the following symptoms during
the majority of days of the current or most recent episode of mania, hypomania, or de-
pression:
1. Feeling keyed up or tense.
2. Feeling unusually restless.
3. Difficulty concentrating because of worry.
4. Fear that something awful may happen.
5. Feeling that the individual might lose control of himself or herself.
Specify current severity:
Mild:  Two symptoms.
Moderate: Three symptoms.
Moderate-severe:  Four or five symptoms.
Severe:  Four or five symptoms with motor agitation.
Note:  Anxious distress has been noted as a prominent feature of both bipolar and
major depressive disorder in both primary care and specialty mental health set-
tings. High levels of anxiety have been associated with higher suicide risk, longer
duration of illness, and greater likelihood of treatment nonresponse. As a result, it
is clinically useful to specify accurately the presence and severity levels of anxious


is clinically useful to specify accurately the presence and severity levels of anxious
distress for treatment planning and monitoring of response to treatment.
With mixed features:  The mixed features specifier can apply to the current manic, hy-
pomanic, or depressive episode in bi polar I or bipolar II disorder:
Manic or hypomanic episode, with mixed features:
A. Full criteria are met for a manic episode or hypomanic episode, and at least
three of the following symptoms are present during the majority of days of the
current or most recent episode of mania or hypomania:
1. Prominent dysphoria or depressed mood as indicated by either subjective
report (e.g., feels sad or empty) or observation made by others (e.g., ap-
pears tearful).
2. Diminished interest or pleasure in all, or almost all, activities (as indicated by
either subjective account or observation made by others).
3. Psychomotor retardation nearly every day (observable by others; not merely
subjective feelings of being slowed down).


150 Bipolar and Related Disorders
4. Fatigue or loss of energy.
5. Feelings of worthlessness or excessive or inappropriate guilt (not merely
self-reproach or guilt about being sick).
6. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ide-
ation without a specific plan, or a suicide attempt or a specific plan for com-
mitting suicide.
B. Mixed symptoms are observable by others and represent a change from the
person’s usual behavior.
C. For individuals whose symptoms meet full episode criteria for both mania and
depression simultaneously, the diagnosis should be manic episode, with mixed
features, due to the marked impairment and clinical severity of full mania.
D. The mixed symptoms are not attributable to the physiological effects of a sub-
stance (e.g., a drug of abuse, a medication, other treatment).
Depressive episode, wit h mixed features:
A. Full criteria are met for a major depressive episode, and at least three of the fol-
lowing manic/hypomanic symptoms are present during the majority of days of
the current or most recent episode of depression:
1. Elevated, expansive mood.
2. Inflated self-esteem or grandiosity.
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Increase in energy or goal-directed activity (either socially, at work or school,
or sexually).
6. Increased or excessive involvement in activities that have a high potential
for painful consequences (e.g., engaging in unrestrained buying sprees,
sexual indiscretions, or foolish business investments).
7. Decreased need for sleep (feeling rested despite sleeping less than usual;
to be contrasted with insomnia).
B. Mixed symptoms are observable by others and represent a change from the


B. Mixed symptoms are observable by others and represent a change from the
person’s usual behavior.
C. For individuals whose symptoms meet full episode criteria for both mania and
depression simultaneously, the diagnosis should be manic episode, with mixed
features.
D. The mixed symptoms are not attributable to the physiological effects of a sub-
stance (e.g., a drug of abuse, a medication, or other treatment).
Note:  Mixed features associated with a major depressive episode have been found
to be a significant risk factor for the development of bipolar I or bipolar II disorder.
As a result, it is clinically useful to note the presence of this specifier for treatment
planning and monitoring of response to treatment.
With rapid cycling  (can be applied to bipolar I or bipolar II disorder): Presence of at
least four mood episodes in the previous 12 months that meet the criteria for manic,
hypomanic, or major depressive episode.
Note:  Episodes are demarcated by either partial or full remissions of at least 2 months
or a switch to an episode of the opposite polarity (e.g., major depressive episode to
manic episode).
Note:  The essential feature of a rapid-cycli ng bipolar disorder is the occurrence of
at least four mood episodes during the previous 12 months. These episodes can
occur in any combination and order. The episodes must meet both the duration and


Specifiers for Bipolar and Related Disorders 151
symptom number criteria for a major depressive, manic, or hypomanic episode and
must be demarcated by either a period of full remission or a switch to an episode
of the opposite polarity. Manic and hypomanic episodes are counted as being on
the same pole. Except for the fact that they occur more frequently, the episodes that
occur in a rapid-cycling pattern are no different from those that occur in a non-rapid-
cycling pattern. Mood episodes that count toward defining a rapid-cycling pattern
exclude those episodes directly caused by a substance (e.g., cocaine, corticoste-
roids) or another medical condition.
With melancholic features:
A. One of the following is present 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. A distinct quality of depressed mood characterized by profound despondency,
despair, and/or moroseness or by so-called empty mood.
2. Depression that is regularly worse in the morning.
3. Early-morning awakening (i.e., at least 2 hours before usual awakening).
4. Marked psychomotor agitation or retardation.
5. Significant anorexia or weight loss.
6. Excessive or inappropriate guilt.
Note:  The specifier “with melancholic features” is applied if these features are pres-
ent at the most severe stage of the episode. There is a near-complete absence of
the capacity for pleasure, not merely a diminution. A guideline for evaluating the
lack of reactivity of mood is that even highly desired events are not associated with


lack of reactivity of mood is that even highly desired events are not associated with
marked brightening of mood. Either mood does not brighten at all, or it brightens
only partially (e.g., up to 20%–40% of normal for only minutes at a time). The “dis-
tinct quality” of mood that is characteristic of the “with melancholic features” speci-
fier is experienced as qualitatively different from that during a nonmelancholic
depressive episode. A depressed mood that is described as merely more severe,
longer lasting, or present without a reason is  not considered distinct in quality. Psy-
chomotor changes are nearly always present and are observable by others.
Melancholic features exhibit only a modest tendency to repeat across episodes
in the same individual. They are more frequent in inpatients, as opposed to outpa-
tients; are less likely to occur in milder than in more severe major depressive epi-
sodes; and are more likely to occur in those with psychotic features.
With atypical features:  This specifier can be applied when these features predomi-
nate during the majority of days of the current or most recent major depressive epi-
sode.
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. A long-standing pattern of interpersonal rejection sensitivity (not limited to epi-
sodes of mood disturbance) that results in significant social or occupational
impairment.


152 Bipolar and Related Disorders
C. Criteria are not met for “with melancholic  features” or “with catatonia” during the
same episode.
Note:  “Atypical depression” has historical significance (i.e., atypical in contradis-
tinction to the more classical agitated, “endogenous” presentations of depression
that were the norm when depression was rarely diagnosed in outpatients and al-
most never in adolescents or younger adults) and today does not connote an un-
common or unusual clinical presentation as the term might imply.
Mood reactivity is the capacity to be cheered up when presented with positive
events (e.g., a visit from children, compliments from others). Mood may become
euthymic (not sad) even for extended periods of time if the external circumstances
remain favorable. Increased appetite may be manifested by an obvious increase in
food intake or by weight gain. Hypersomnia may include either an extended period
of nighttime sleep or daytime napping that totals at least 10 hours of sleep per day
(or at least 2 hours more than when not depressed). Leaden paralysis is defined as
feeling heavy, leaden, or weighted down, usually in the arms or legs. This sensation
is generally present for at least an hour a day but often lasts for many hours at a
time. Unlike the other atypical features, pathological sensitivity to perceived inter-
personal rejection is a trait that has an early onset and persists throughout most of
adult life. Rejection sensitivity occurs both when the person is and is not depressed,
though it may be exacerbated during depressive periods.
With psychotic features:  Delusions or hallucinations are present at any time in the
episode. If psychotic features are present, specify if mood-congruent or mood-incon-
gruent:
With mood-congruent psychotic features: During manic episodes, the con-


gruent:
With mood-congruent psychotic features: During manic episodes, the con-
tent of all delusions and hallucinations is consistent with the typical manic
themes of grandiosity, invulnerability, etc., but may also include themes of sus-
piciousness or paranoia, especially with respect to others’ doubts about the in-
dividual’s capacities, accomplishments, and so forth.
With mood-incongruent  psychotic features:  The content of delusions and
hallucinations is inconsistent with the episode polarity themes as described
above, or the content is a mixture of mood-incongruent and mood-congruent
themes.
With catatonia:  This specifier can apply to an episode of mania or depression if cata-
tonic features are present during most of the episode. See criteria for catatonia asso-
ciated with a mental disorder in the chapter “Schizophrenia Spectrum and Other
Psychotic Disorders.”
With peripartum onset: This specifier can be applied to the current or, if the full crite-
ria are not currently met for a mood episode, most recent episode of mania, hypoma-
nia, or major depression in bipolar I or bipol ar II disorder if onset of mood symptoms
occurs during pregnancy or in the 4 weeks following delivery.
Note:  Mood episodes can have their onset either during pregnancy or postpartum.
Although the estimates differ according to the period of follow-up after delivery, be-
tween 3% and 6% of women will experience the onset of a major depressive epi-
sode during pregnancy or in the weeks or months following delivery. Fifty percent
of “postpartum” major depressive episodes actually begin prior to delivery. Thus,
these episodes are referred to collectively as peripartum episodes. Women with


these episodes are referred to collectively as peripartum episodes. Women with
peripartum major depressive episodes often have severe anxiety and even panic
attacks. Prospective studies have demonstrated that mood and anxiety symptoms
during pregnancy, as well as the “baby blues,” increase the risk for a postpartum
major depressive episode.


Specifiers for Bipolar and Related Disorders 153
Peripartum-onset mood episodes can pres ent either with or without psychotic
features. Infanticide is most often associated with postpartum psychotic episodes
that are characterized by command hallucinations to kill the infant or delusions that
the infant is possessed, but psychotic symptoms can also occur in severe postpar-
tum mood episodes without such specific delusions or hallucinations.
Postpartum mood (major depressive or manic) episodes with psychotic features
appear to occur in from 1 in 500 to 1 in 1,000 deliveries and may be more common
in primiparous women. The risk of postpartum episodes with psychotic features is
particularly increased for women with prior postpartum mood episodes but is also
elevated for those with a prior history of a depressive or bipolar disorder (especially
bipolar I disorder) and those with a family history of bipolar disorders.
Once a woman has had a postpartum episode with psychotic features, the risk
of recurrence with each subsequent delivery is between 30% and 50%. Postpartum
episodes must be differentiated from delirium occurring in the postpartum period,
which is distinguished by a fluctuating level of awareness or attention. The postpar-
tum period is unique with respect to the degree of neuroendocrine alterations and
psychosocial adjustments, the potential impact of breast-feeding on treatment plan-
ning, and the long-term implications of a history of postpartum mood disorder on sub-
sequent family planning.
With seasonal pattern:  This specifier applies to the lifetime pattern of mood episodes.
The essential feature is a regular seasonal pattern of at least one type of episode (i.e.,
mania, hypomania, or depression). The other types of episodes may not follow this pat-


tern. For example, an individual may have seasonal manias, but his or her depressions
do not regularly occur at a specific time of year.
A. There has been a regular temporal relationship between the onset of manic, hypo-
manic, or major depressive episodes and a particular time of the year (e.g., in the
fall or winter) in bipolar I or bipolar II disorder.
Note:  Do not include cases in which there is an obvious effect of seasonally related
psychosocial stressors (e.g., regularly being unemployed every winter).
B. Full remissions (or a change from major depression to mania or hypomania or vice
versa) also occur at a characteristic time of the year (e.g., depression disappears
in the spring).
C. In the last 2 years, the individual’s manic, hypomanic, or major depressive episodes
have demonstrated a temporal seasonal relationship, as defined above, and no
non-seasonal episodes of that polarity have occurred during that 2-year period.
D. Seasonal manias, hypomanias, or depressions (as described above) substantially
outnumber any nonseasonal manias, hypomanias, or depressions that may have
occurred over the individual’s lifetime.
Note:  This specifier can be applied to the pattern of major depressive episodes in
bipolar I disorder, bipolar II disorder, or  major depressive disorder, recurrent. The
essential feature is the onset and remission of major depressive episodes at char-
acteristic times of the year. In most cases, the episodes begin in fall or winter and
remit in spring. Less commonly, there may be recurrent summer depressive epi-
sodes. This pattern of onset and remission of episodes must have occurred during
at least a 2-year period, without any nonseasonal episodes occurring during this


at least a 2-year period, without any nonseasonal episodes occurring during this
period. In addition, the seasonal depressi ve episodes must substantially outnum-
ber any nonseasonal depressive episodes over the individual’s lifetime.
This specifier does not apply to those situations in which the pattern is better ex-
plained by seasonally linked psychosocial stressors (e.g., seasonal unemployment
or school schedule). Major depressive episodes that occur in a seasonal pattern


154 Bipolar and Related Disorders
are often characterized by prominent energy, hypersomnia, overeating, weight
gain, and a craving for carbohydrates. It is unclear whether a seasonal pattern is
more likely in recurrent major depressive di sorder or in bipolar disorders. However,
within the bipolar disorders group, a seasonal pattern appears to be more likely in
bipolar II disorder than in bipolar I disorder. In some individuals, the onset of manic
or hypomanic episodes may also be linked to a particular season.
The prevalence of winter-type seasonal pattern appears to vary with latitude,
age, and sex. Prevalence increases with higher  latitudes. Age is also a strong pre-
dictor of seasonality, with younger persons at higher risk for winter depressive epi-
sodes.
Specify if:
In partial remission: Symptoms of the immediately previous manic, hypomanic, or
depressive episode are present, but full criteria are not met, or there is a period lasting
less than 2 months without any significant symptoms of a manic, hypomanic, or major
depressive episode following the end of such an episode.
In full remission:  During the past 2 months, no significant signs or symptoms of the
disturbance were present.
Specify current severity:
Severity is based on the number of criterion symptoms, the severity of those symptoms,
and the degree of functional disability.
Mild:  Few, if any, symptoms in excess of those required to meet the diagnostic criteria
are present, the intensity of the symptoms is distressing but manageable, and the
symptoms result in minor impairment in social or occupational functioning.
Moderate: The number of symptoms, intensity of symptoms, and/or functional impair-
ment are between those specified for “mild” and “severe.”


ment are between those specified for “mild” and “severe.”
Severe:  The number of symptoms is substantially in excess of those required to make
the diagnosis, the intensity of the symptoms is seriously distressing and unmanage-
able, and the symptoms markedly interfere with social and occupational functioning.


155Depressive
Disorders
Depressive disorders  include disruptive mood dysregulation disorder, major
depressive disorder (including  major depressive episode), persistent depressive disorder
(dysthymia), premenstrual dysphoric disord er, substance/medication-induced depres-
sive disorder, depressive disord er due to another medical co ndition, other specified de-
pressive disorder, and unspec ified depressive disorder. Unlike in DSM-IV, this chapter
“Depressive Disorders” has been separated fr om the previous chapter “Bipolar and Re-
lated Disorders.” The common feature of all of these disorders is the presence of sad,
empty, or irritable mood, accompanied by somatic and cognitive changes that signifi-
cantly affect the individual’s capacity to function. What differs among them are issues of
duration, timing, or presumed etiology.
In order to address concerns about the pote ntial for the overdiagnosis of and treatment
for bipolar disorder in children, a new diagno sis, disruptive mood dysregulation disorder,
referring to the presentation of children wi th persistent irritability and frequent episodes
of extreme behavioral dyscontrol, is added to the depressive disorders for children up to
12 years of age. Its placement in this chapter reflects the finding that children with this
symptom pattern typica lly develop unipolar depressive disorders or anxiety disorders,
rather than bipolar disorders, as they  mature into adolescence and adulthood.
Major depressive disorder represents the clas sic condition in this gr oup of disorders. It
is characterized by discrete episodes of at least 2 weeks’ duration (although most episodes
last considerably longer) involving clear-cut changes in affect, cogn ition, and neurovege-
tative functions and inter-episode remissions.  A diagnosis based on a single episode is


tative functions and inter-episode remissions.  A diagnosis based on a single episode is
possible, although the disorder is a recurrent one in the majori ty of cases. Careful consid-
eration is given to the delineation of normal sadness and grief from a major depressive ep-
isode. Bereavement may induce great suffering, but it does not typically induce an episode
of major depressive disorder. When they do occur together, the depressive symptoms and
functional impairment tend to be more seve re and the prognosis is worse compared with
bereavement that is not accompanied by majo r depressive disorder. Bereavement-related
depression tends to occur in persons with other vulnerabilities to depressive disorders,
and recovery may be facilitated by antidepressant treatment.
A more chronic form of depression, persiste nt depressive disorder  (dysthymia), can be
diagnosed when the mood disturbance continues for at least 2 years in adults or 1 year in
children. This diagnosis, new in DSM-5, includes both the DSM-IV diagnostic categories of
chronic major depression and dysthymia.
After careful scientific review of the evid ence, premenstrual dy sphoric disorder has
been moved from an appendix of DSM-IV (“ Criteria Sets and Axes Provided for Further
Study”) to Section II of DSM-5. Almost 20 years of additional of research on this condition
has confirmed a specific and treatment-responsi ve form of depressive  disorder that begins
sometime following ovulation and remits within a few days of menses and has a marked
impact on functioning.
A large number of substances of abuse, some prescribed medi cations, and several
medical conditions can be associated with de pression-like phenomena. This fact is recog-
nized in the diagnoses of substance/medicati on-induced depressive disorder and depres-


nized in the diagnoses of substance/medicati on-induced depressive disorder and depres-
sive disorder due to an other medical condition.


156 Depressive Disorders
Disruptive Mood Dysregulation Disorder
Diagnostic Criteria 296.99 (F34.8)
A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or be-
haviorally (e.g., physical aggression toward people or property) that are grossly out of
proportion in intensity or duration to the situation or provocation.
B. The temper outbursts are inconsistent with developmental level.
C. The temper outbursts occur, on aver age, three or more times per week.
D. The mood between temper outbursts is persistently irritable or angry most of the day,
nearly every day, and is observable by others (e.g., parents, teachers, peers).
E. Criteria A–D have been present for 12 or more months. Throughout that time, the indi-
vidual has not had a period lasting 3 or more consecutive months without all of the
symptoms in Criteria A–D.
F. Criteria A and D are present in at least two of three settings (i.e., at home, at school,
with peers) and are severe in at least one of these.
G. The diagnosis should not be made for the first time before age 6 years or after age 18
years.
H. By history or observation, the age at onset of Criteria A–E is before 10 years.
I. There has never been a distinct period lasting more than 1 day during which the full
symptom criteria, except duration, fo r a manic or hypomanic episode have been met.
Note:  Developmentally appropriate mood elevation, such as occurs in the context of a
highly positive event or its anticipation, should not be considered as a symptom of ma-
nia or hypomania.


nia or hypomania.
J. The behaviors do not occur exclusively during an episode of major depressive disorder
and are not better explained by another mental disorder (e.g., autism spectrum disor-
der, posttraumatic stress disorder, separat ion anxiety disorder, persistent depressive
disorder [dysthymia]).
Note:  This diagnosis cannot coexist with oppositional defiant disorder, intermittent ex-
plosive disorder, or bipolar disorder, though it can coexist with others, including major
depressive disorder, attention-deficit/hy peractivity disorder, conduct disorder, and
substance use disorders. Individuals whose symptoms meet criteria for both disruptive
mood dysregulation disorder and oppositional defiant disorder should only be given the
diagnosis of disruptive mood dysregulation disorder. If an individual has ever experi-
enced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation
disorder should not be assigned.
K. The symptoms are not attributable to the physiological effects of a substance or to an-
other medical or neurological condition.
Diagnostic Features
The core feature of disruptive mood dysregulat ion disorder is chronic, severe persistent ir-
ritability. This severe irritability has two prominent clinical mani festations, the first of
which is frequent temper outbursts. These ou tbursts typically occur in response to frus-
tration and can be verbal or behavioral (the la tter in the form of aggression against prop-
erty, self, or others). They must occur frequent ly (i.e., on average, three or more times per
week) (Criterion C) over at least 1 year in at least two settings (Criteria E and F), such as in
the home and at school, and th ey must be developmentally inappropriate (Criterion B).


the home and at school, and th ey must be developmentally inappropriate (Criterion B).
The second manifestation of severe irritability consists of chronic, persistently irritable or
angry mood that is present between the severe temper outbursts. This irritable or angry
mood must be characteristic of the child, bein g present most of the day, nearly every day,
and noticeable by others in the child’s environment (Criterion D).


Disruptive Mood Dysregulation Disorder 157
The clinical presentation of disruptive mo od dysregulation disord er must be carefully
distinguished from presentations of other, re lated conditions, particularly pediatric bi-
polar disorder. In fact, disruptive mood dy sregulation disorder was added to DSM-5 to
address the considerable concern about the appropriate classification and treatment of
children who present with chronic, persistent irritability relative to children who present
with classic (i.e., episo dic) bipolar disorder.
Some researchers view severe, non-episodic ir ritability as characteristic of bipolar dis-
order in children, although both DSM-IV and DSM-5 require that both children and adults
have distinct episodes of mania or hypomania to qualify for the diagnosis of bipolar I dis-
order. During the latter decades of the 20th century, this contention by researchers that
severe, nonepisodic irritability is a manifestat ion of pediatric mania coincided with an up-
surge in the rates at which clinicians assigned the diagnosis of bipolar disorder to their
pediatric patients. This sharp increase in rates appears to be attributab le to clinicians com-
bining at least two clinical presentations into a single category. That is, both classic, epi-
sodic presentations of mania and non-episodic  presentations of severe irritability have
been labeled as bipolar disorder in children. In DSM-5, the term bipolar disorder  is explicitly
reserved for episodic presentations of bipolar symptoms. DSM-IV did not include a diagno-
sis designed to capture youths whose hallmar k symptoms consisted of very severe, non-
episodic irritability, whereas DSM-5, with the inclusion of disruptive mood dysregulation
disorder, provides a distinct ca tegory for such presentations.
Prevalence


disorder, provides a distinct ca tegory for such presentations.
Prevalence
Disruptive mood dysregulatio n disorder is common among children presenting to pedi-
atric mental health clinics. Prevalence estima tes of the disorder in the community are un-
clear. Based on rates of chronic and severe pe rsistent irritability, which is the core feature
of the disorder, the overall 6-month to 1-year period-prevale nce of disruptive mood dys-
regulation disorder among children and adolescents probably falls in the 2%–5% range.
However, rates are expected to be higher in males and school-age children than in females
and adolescents.
Development and Course
The onset of disruptive mood dysregulation diso rder must be before age 10 years, and the
diagnosis should not be applied to children with a developmental age of less than 6 years.
It is unknown whether the condition presents only in this age-delimited fashion. Because
the symptoms of disruptive mood dysregulat ion disorder are likely to change as children
mature, use of the diagnosis shou ld be restricted to age grou ps similar to those in which
validity has been established (7–18 years). A pproximately half of children with severe,
chronic irritability will have a presentation that  continues to meet crit eria for the condition
1 year later. Rates of conversion from seve re, nonepisodic irritability to bipolar disorder
are very low. Instead, children with chronic irritability are at risk to develop unipolar de-
pressive and/or anxiety disorders in adulthood.
Age-related variations also differentiate cl assic bipolar disorder  and disruptive mood
dysregulation disorder. Rates of bipolar disorder generally are very low prior to adoles-


dysregulation disorder. Rates of bipolar disorder generally are very low prior to adoles-
cence (<1%), with a steady increase into early adulthood (1%–2% prevalence). Disruptive
mood dysregulation disorder is more common th an bipolar disorder prior to adolescence,
and symptoms of the condition generally be come less common as children transition into
adulthood.
Risk and Prognostic Factors
Temperamental. Children with chronic irritability typically exhibit complicated psy-
chiatric histories. In such children, a relati vely extensive history of chronic irritability is


158 Depressive Disorders
common, typically manifesting be fore full criteria for the syndrome are met. Such predi-
agnostic presentations may have qualified for a diagnosis of oppositional defiant disorder.
Many children with disruptive mood dysregulation disorder have symptoms that also
meet criteria for atte ntion-deficit/hyperactivity disorder  (ADHD) and for an anxiety dis-
order, with such diagnoses often being presen t from a relatively early age. For some chil-
dren, the criteria for major depres sive disorder may also be met.
Genetic and physiological. In terms of familial aggregat ion and genetics, it has been
suggested that children presenting with chronic, non-episodic irritability can be differen-
tiated from children with bipolar disorder in  their family-based risk. However, these two
groups do not differ in familial rates of anxi ety disorders, unipolar  depressive disorders,
or substance abuse. Compared with children with pediatric bipolar disorder or other men-
tal illnesses, those with disruptive mood dy sregulation disorder exhibit both commonal-
ities and differences in information-proce ssing deficits. For example, face-emotion
labeling deficits, as well as perturbed decision  making and cognitive control, are present in
children with bipolar disorder and chronica lly irritable children, as well as in children
with some other psychiatric conditions. There is also evidence for disorder-specific dys-
function, such as during tasks assessing atte ntion deployment in response to emotional
stimuli, which has demonstrated unique signs of dysfunction in children with chronic ir-
ritability.
Gender-Related Diagnostic Issues
Children presenting to clinics with features of  disruptive mood dysr egulation disorder are
predominantly male. Among co mmunity samples, a male pr eponderance appears to be


supported. This difference in prevalence betw een males and females differentiates disrup-
tive mood dysregulation disord er from bipolar disorder, in which there is an equal gender
prevalence.
Suicide Risk
In general, evidence documenting suicidal be havior and aggression, as well as other se-
vere functional consequences, in disruptive mood dysregulation diso rder should be noted
when evaluating children with chronic irritability.
Functional Consequences of
Disruptive Mood Dy sregulation Disorder
Chronic, severe irritability, su ch as is seen in disruptive mood dysregulation disorder, is
associated with marked disruption in a child’ s family and peer relationships, as well as in
school performance. Because of their extrem ely low frustration tole rance, such children
generally have difficulty succeeding in school; they are often unable to participate in the
activities typically enjoyed by healthy children;  their family life is severely disrupted by
their outbursts and irritability; and they have trouble initiating or sustaining friendships.
Levels of dysfunction in childr en with bipolar disorder and disruptive mood  dysregulation
disorder are generally comparable. Both condit ions cause severe disruption in the lives of
the affected individual and their families. In  both disruptive mood dysregulation disorder
and pediatric bipolar disorder, dangerous behavi or, suicidal ideation or suicide attempts,
severe aggression, and psychiatric hospitalization are common.
Differential Diagnosis
Because chronically irritable children and adolescents typically present with complex histo-
ries, the diagnosis of disruptive mood dysreg ulation disorder must be made while consid-
ering the presence or absence of multiple ot her conditions. Despite the need to consider


Disruptive Mood Dysregulation Disorder 159
many other syndromes, differentiation of disr uptive mood dysregulation disorder from bi-
polar disorder and oppositional  defiant disorder requires pa rticularly careful assessment.
Bipolar disorders. The central feature differentiating disruptive mood dysregulation disor-
der and bipolar disorders in children involves the longitudinal course of the core symptoms. In
children, as in adults, bipolar I disorder and bipo lar II disorder manifest as an episodic illness
with discrete episodes of mood perturbation that can be differentiated from the child’s typical
presentation. The mood perturbation that occurs  during a manic episode is distinctly different
from the child’s usual mood. In addition, during a manic episode, the change in mood must be
accompanied by the onset, or worsening, of associated cognitive, behavioral, and physical
symptoms (e.g., distractibility, increased goal-dir ected activity), which are also present to a de-
gree that is distinctly different from the child’s  usual baseline. Thus, in the case of a manic ep-
isode, parents (and, depending on  developmental level, children) should be able to identify a
distinct time period during which the child’s  mood and behavior were markedly different
from usual. In contrast, the irritability of disr uptive mood dysregulation disorder is persistent
and is present over many months; while it may wax and wane to a certain degree, severe irri-
tability is characteristic of the child with disr uptive mood dysregulation disorder. Thus, while
bipolar disorders are episodic conditions, disrup tive mood dysregulation disorder is not. In
fact, the diagnosis of di sruptive mood dysregulation disorder  cannot be assi gned to a child


who has ever experienced a full-duration hypoma nic or manic episode (irritable or euphoric)
or who has ever had a manic or hypomanic epis ode lasting more than 1 day. Another central
differentiating feature between bipolar disorder s and disruptive mood dysregulation disorder
is the presence of elevated or expansive mood and grandiosity. These symptoms are common
features of mania but are not characteristic of disruptive mood dy sregulation disorder.
Oppositional defiant disorder. While symptoms of opposition al defiant disorder typi-
cally do occur in children with disruptive mood dysregulation disorder, mood symptoms
of disruptive mood dysregulation disorder ar e relatively rare in children with opposi-
tional defiant disorder. The key features that warrant the diagnosis of disruptive mood
dysregulation disorder in children whose sympto ms also meet criteria  for oppositional de-
fiant disorder are the presence of severe an d frequently recurrent outbursts and a persis-
tent disruption in mood betw een outbursts. In addition, the diagnosis of disruptive mood
dysregulation disorder requires severe impairment in at least one setting (i.e., home,
school, or among peers) and mild  to moderate impairment in a second setting. For this rea-
son, while most children whose symptoms meet  criteria for disrup tive mood dysregula-
tion disorder will also have a presentation that meets criteria fo r oppositional defiant
disorder, the reverse is not the case. That is, in only approximately 15% of individuals with
oppositional defiant disorder would criteria  for disruptive mood dysregulation disorder
be met. Moreover, even for child ren in whom criteria for both disorders are met, only the
diagnosis of disruptive mood dysregulation disorder should be made. Finally, both the


diagnosis of disruptive mood dysregulation disorder should be made. Finally, both the
prominent mood symptoms in disruptive mood  dysregulation disorder and the high risk
for depressive and anxiety disorders in follow -up studies justify placement of disruptive
mood dysregulation disorder among the depr essive disorders in DSM-5. (Oppositional
defiant disorder is included in the chapter “Disruptive, Impulse-Control, and Conduct
Disorders.”) This reflects the more prominent mood comp onent among individuals with


defiant disorder is included in the chapter “Disruptive, Impulse-Control, and Conduct
Disorders.”) This reflects the more prominent mood comp onent among individuals with
disruptive mood dysregulation disorder, as compared with individuals with oppositional
defiant disorder. Nevertheless, it  also should be noted that disruptive mood dysregulation
disorder appears to carry a high risk for be havioral pr oblems as well as mood problems.
Attention-deficit/hyperactivity disorder, ma jor depressive disorder, anxiety disorders,
and autism spectrum disorder. Unlike children diagnosed with bipolar disorder or op-
positional defiant disorder, a child whose sy mptoms meet criteria for disruptive mood
dysregulation disorder also can receive a co morbid diagnosis of ADHD, major depressive
disorder, and/or anxiety disorder. However, children whose irritability is present only in
the context of a major depressive episode or persistent depressive disorder (dysthymia)


160 Depressive Disorders
should receive one of those di agnoses rather than disrupti ve mood dysregulation disor-
der. Children with disruptive mood dysregul ation disorder may have symptoms that also
meet criteria for an anxiety disorder and can receive both diagnoses, but children whose ir-
ritability is manifest only in the context of exacerbation of an anxiety disorder should re-
ceive the relevant anxiety disorder diagnosis rather than disruptive  mood dysregulation
disorder. In addition, children  with autism spectrum diso rders frequently present with
temper outbursts when, for example, their rout ines are disturbed. In that instance, the
temper outbursts would be considered secondary to the au tism spectrum disorder, and
the child should not receive the diagnosis of disruptive mood dysregulation disorder.
Intermittent explosive disorder. Children with symptoms su ggestive of intermittent
explosive disorder present with instances of severe temper outburst s, much like children
with disruptive mood dysregulation disorder. However, unlike disruptive mood dysreg-
ulation disorder, intermittent explosive disorder does not re quire persistent disruption in
mood between outbursts. In addition, intermittent explosive disorder requires only 3 months
of active symptoms, in contrast to the 12- month requirement for disruptive mood dys-
regulation disorder. Thus, these two diagnoses should not be made in the same child. For
children with outbursts and intercurrent, persis tent irritability, only the diagnosis of dis-
ruptive mood dysregulation disorder should be made.
Comorbidity
Rates of comorbidity in disruptive mood dysr egulation disorder are extremely high. It is
rare to find individuals whose symptoms meet  criteria for disrupti ve mood dysregulation
disorder alone. Comorbidity between disrupti ve mood dysregulatio n disorder and other


DSM-defined syndromes appears higher than for many other pediatric mental illnesses;
the strongest overlap is with oppositional de fiant disorder. Not only  is the overall rate of
comorbidity high in disruptive mood dysregul ation disorder, but also the range of comor-
bid illnesses appears particularly diverse. These children typically present to the clinic
with a wide range of disruptive behavior , mood, anxiety, and even autism spectrum
symptoms and diagnoses. Howe ver, children with disruptive  mood dysregulation disor-
der should not have symptoms that meet criter ia for bipolar disorder, as in that context,
only the bipolar disorder di agnosis should be made. If children have symptoms that meet
criteria for oppositional defiant disorder or intermittent explosive disorder and disruptive
mood dysregulation disorder, only the diagnosis of disruptive mood dysregulation disor-
der should be assigned. Also, as noted earlier, the diagnosis of disruptive mood dysregu-
lation disorder should not be assigned if the symptoms occur only in an anxiety-
provoking context, when the routines of a ch ild with autism spectrum disorder or obses-
sive-compulsive disorder are disturbed, or in the context of  a major depressive episode.
Major Depressive Disorder
Diagnostic Criteria
A. Five (or more) of the following symptoms have been present during the same 2-week
period and represent a change from previous functioning; at least one of the symptoms
is either (1) depressed mood or (2) loss of interest or pleasure.
Note:  Do not include symptoms that are clearly  attributable to another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjec-
tive report (e.g., feels sad, empty, hopeless) or observation made by others (e.g.,


appears tearful). ( Note:  In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in al l, or almost all, activities most of the
day, nearly every day (as indicated by either subjective account or observation).


Major Depressive Disorder 161
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than
5% of body weight in a month), or decreas e or increase in appetite nearly every day.
(Note:  In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not
merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delu-
sional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (ei-
ther by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with-
out a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or to another
medical condition.
Note:  Criteria A–C represent a major depressive episode.
Note:  Responses to a significant loss (e.g., bereavement, financial ruin, losses from a nat-
ural disaster, a serious medical illness or disa bility) may include the feelings of intense sad-
ness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A,
which may resemble a depressive episode. Although such symptoms may be understand-
able or considered appropriate to the loss, the presence of a major depressive episode in


able or considered appropriate to the loss, the presence of a major depressive episode in
addition to the normal response to a significant loss should also be carefully considered. This
decision inevitably requires the ex ercise of clinical judgment ba sed on the individual’s history
and the cultural norms for the expression of distress in the context of loss.1
D. The occurrence of the major depressive episode is not better explained by schizoaf-
fective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or
other specified and unspecified schizophrenia s pectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode.
Note:  This exclusion does not apply if all of the manic-like or hypomanic-like episodes
are substance-induced or are attributable to  the physiological effects of another med-
ical condition.
1In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in
grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent
depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is
likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of
grief. These waves tend to be associated with thoughts or reminders of the deceased. The
depressed mood of MDE is more persistent and not tied to specific thoughts or preoccupations.
The pain of grief may be accompanied by positi ve emotions and humor th at are uncharacteristic
of the pervasive unhappiness and misery characteristic of MDE. The thought content associated
with grief generally features a preoccupation with thoughts and memories of the deceased,
rather than the self-critical or pessimistic ruminati ons seen in MDE. In grief, self-esteem is gener-


ally preserved, whereas in MDE feelings of wort hlessness and self-loathing are common. If self-
derogatory ideation is present in grief, it ty pically involves perceived failings vis-à-vis the
deceased (e.g., not visiting frequently enough, no t telling the deceased how much he or she was
loved). If a bereaved individual thinks abou t death and dying, such thoughts are generally
focused on the deceased and possibly about “joining” the de ceased, whereas in MDE such


loved). If a bereaved individual thinks abou t death and dying, such thoughts are generally
focused on the deceased and possibly about “joining” the de ceased, whereas in MDE such
thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life,
or unable to cope with the pain of depression.


162 Depressive Disorders
Coding and Recording Procedures
The diagnostic code for major depressive disorder is based on whether this is a single or
recurrent episode, current severity, presence of psychotic features, and remission status.
Current severity and psychotic features are only indicated if full criteria are currently met
for a major depressive episode. Remission specifiers are only indicated if the full criteria
are not currently met for a major depressive episode. Codes are as follows:
In recording the name of a diagnosis, terms should be listed in the following order: major
depressive disorder, single or recurrent epis ode, severity/psychotic/remission specifiers,
followed by as many of the following specifiers without codes that apply to the current
episode.
Specify:
With anxious distress (p. 184)
With mixed features (pp. 184–185)
With melancholic features (p. 185)
With atypical features  (pp. 185–186)
With mood-congruent psychotic features (p. 186)
With mood-incongruen t psychotic features  (p. 186)
With catatonia  (p. 186). Coding note:  Use additional code 293.89 (F06.1).
With peripartum onset  (pp. 186–187)
With seasonal pattern (recurrent episode only) (pp. 187–188)
Diagnostic Features
The criterion symptoms for majo r depressive disorder must be  present nearly every day to
be considered present, with the exception of  weight change and suicidal ideation. De-
pressed mood must be present for most of the day, in addition to being present nearly ev-
ery day. Often insomnia or fatigue is the presenting complaint, and failure to probe for
accompanying depressive symptoms will result in underdiagnosis. Sadness may be de-


accompanying depressive symptoms will result in underdiagnosis. Sadness may be de-
nied at first but may be elicit ed through interview or inferred from facial expression and
demeanor. With individuals wh o focus on a somatic complaint, clinicians should de-
termine whether the distress from that comp laint is associated with specific depressive
symptoms. Fatigue and sleep disturbance are present in a high propor tion of cases; psy-
chomotor disturbances are much less common but are indicative of greater overall sever-
ity, as is the presence of delu sional or near-delusional guilt.Severity/course specifier Single episode Recurrent episode*
Mild (p. 188) 296.21 (F32.0) 296.31 (F33.0)
Moderate (p. 188) 296.22 (F32.1) 296.32 (F33.1)
Severe (p. 188) 296.23 (F32.2) 296.33 (F33.2)
With psychotic features** (p. 186) 296.24 (F32.3) 296.34 (F33.3)
In partial remission (p. 188) 296.25 (F32.4) 296.35 (F33.41)
In full remission (p. 188) 296.26 (F32.5) 296.36 (F33.42)
Unspecified 296.20 (F32.9) 296.30 (F33.9)
*For an episode to be considered recurrent, there must be an interval  of at least 2 consecutive months
between separate episodes in which criteria are no t met for a major depressive episode. The defini-


tions of specifiers are found on the indicated pages.
**If psychotic features are present,  code the “with psychotic features ” specifier irrespective of epi-
sode severity.


Major Depressive Disorder 163
The essential feature of a major depressive episode is a period of at least 2 weeks during
which there is either depressed mood or the loss of interest or pleasure in nearly all activi-
ties (Criterion A). In children and adolescents,  the mood may be irritable rather than sad.
The individual must also expe rience at least four additional symptoms drawn from a list
that includes changes in appetite or weigh t, sleep, and psychomotor activity; decreased en-
ergy; feelings of worthlessness or guilt; difficulty thinking, co ncentrating, or making deci-
sions; or recurrent thoughts of death or suicid al ideation or suicide plans or attempts. To
count toward a major depressive episode, a sy mptom must either be newly present or must
have clearly worsened compared with the person’s pre- episode status. The symptoms
must persist for most of the day, nearly every day, for at least 2 consecutive weeks. The ep-
isode must be accompanied by clinically signif icant distress or impairment in social, occu-
pational, or other important areas of func tioning. For some in dividuals with milder
episodes, functioning may appear  to be normal but requires markedly increased effort.
The mood in a major depressive episode is of ten described by the person as depressed,
sad, hopeless, discouraged, or “down in the du mps” (Criterion A1). In some cases, sadness
may be denied at first but may subsequently be  elicited by interview (e.g., by pointing out
that the individual looks as if he or she is ab out to cry). In some individuals who complain
of feeling “blah,” having no feelings, or feeling anxious, the presence of a depressed mood
can be inferred from the pers on’s facial expression and de meanor. Some individuals em-


can be inferred from the pers on’s facial expression and de meanor. Some individuals em-
phasize somatic complaints (e.g., bodily aches and pains) rather than reporting feelings of
sadness. Many individuals report or exhibit in creased irritability (e.g.,  persistent anger, a
tendency to respond to events with angry outbursts or blaming ot hers, an exaggerated
sense of frustration over minor matters). In ch ildren and adolescents, an irritable or cranky
mood may develop rather than a sad or dejected mood. This presenta tion should be dif-
ferentiated from a pattern of irritability when frustrated.
Loss of interest or pleasure is nearly always  present, at least to some degree. Individ-
uals may report feeling less interested in hobb ies, “not caring anymore,” or not feeling any
enjoyment in activities that were previously considered pleasurable (Criterion A2). Family
members often notice social withdrawal or ne glect of pleasurable avocations (e.g., a for-
merly avid golfer no longer plays, a child who used to enjoy soccer finds excuses not to
practice). In some individuals,  there is a significant reduction from previous levels of sex-
ual interest or desire.
Appetite change may involve either a redu ction or increase. Some depressed individ-
uals report that they have to force themselv es to eat. Others may eat more and may crave
specific foods (e.g., sweets or other carbohydrates). When appetite changes are severe (in
either direction), there may be a significant loss  or gain in weight, or , in children, a failure
to make expected weight gains may be noted (Criterion A3).
Sleep disturbance may take the form of either difficulty sleepin g or sleeping exces-


Sleep disturbance may take the form of either difficulty sleepin g or sleeping exces-
sively (Criterion A4). When insomnia is presen t, it typically takes the form of middle in-
somnia (i.e., waking up during the night an d then having difficulty returning to sleep) or
terminal insomnia (i.e., waking too early and be ing unable to return to sleep). Initial in-
somnia (i.e., difficulty falling asleep) may al so occur. Individuals who present with over-
sleeping (hypersomn ia) may experience prolonged sleep episodes at night or increased
daytime sleep. Sometimes the reason that the individual seeks trea tment is for the dis-
turbed sleep.


sleeping (hypersomn ia) may experience prolonged sleep episodes at night or increased
daytime sleep. Sometimes the reason that the individual seeks trea tment is for the dis-
turbed sleep.
Psychomotor changes include agitation (e.g., the inabili ty to sit still, pacing, hand-
wringing; or pulling or rubbing of the skin, cl othing, or other objects)  or retardation (e.g.,
slowed speech, thinking, and body movements; increased pauses before answering;
speech that is decreased in vo lume, inflection, amount, or variety of content, or muteness)
(Criterion A5). The psychomotor agitation or retardation must be severe enough to be ob-
servable by others and not repres ent merely subjective feelings.
Decreased energy, tiredness, and fatigue are common (Criterion A6). A person may re-
port sustained fatigue without physical exertion . Even the smallest ta sks seem to require


164 Depressive Disorders
substantial effort. The efficiency with whic h tasks are accomplished may be reduced. For
example, an individual may complain that washing and dressing in the morning are ex-
hausting and take twice as long as usual.
The sense of worthlessness or guilt associated with a major depressive episode may in-
clude unrealistic negative evaluations of one’ s worth or guilty preoccupations or rumina-
tions over minor past failings (Criterion A7). Such individu als often misinterpret neutral
or trivial day-to-day events as  evidence of personal defects and have an exaggerated sense
of responsibility for untoward events. The sens e of worthlessness or guilt may be of delu-
sional proportions (e.g., an individual who is convinced that he or she is personally re-
sponsible for world poverty). Blaming oneself for being sick and for failing to meet
occupational or interpersonal responsibilities as  a result of the depression is very common
and, unless delusional, is not consider ed sufficient to meet this criterion.
Many individuals report impaired ability to  think, concentrate, or make even minor
decisions (Criterion A8). They may appear ea sily distracted or complain of memory diffi-
culties. Those engaged in cogn itively demanding pursuits are often unable to function. In
children, a precipitous drop in grades may reflect poor concentratio n. In elderly individ-
uals, memory difficulties may be the chief co mplaint and may be mistaken for early signs
of a dementia (“pseudodementia”). When th e major depressive ep isode is successfully
treated, the memory problems often fully abate. However, in some individuals, particu-
larly elderly persons, a major depressive ep isode may sometimes be the initial presenta-
tion of an irreve rsible dementia.


tion of an irreve rsible dementia.
Thoughts of death, suicidal ideation, or suicide attempts (Cri terion A9) are common.
They may range from a passive wish not to aw aken in the morning or a belief that others
would be better off if the individual were dead , to transient but recurrent thoughts of com-
mitting suicide, to a specific suicide plan. Mo re severely suicidal individuals may have put
their affairs in order (e.g., up dated wills, settled debts), acqu ired needed materials (e.g., a
rope or a gun), and chosen a location and time  to accomplish the suicide. Motivations for
suicide may include a desire to give up in th e face of perceived insurmountable obstacles,
an intense wish to end what is perceived as an unending and excruciatingly painful emo-
tional state, an inability to fo resee any enjoyment in life, or the wish to not be a burden to
others. The resolution of such thinking may be a more meaningful measure of diminished
suicide risk than denial of further plans for suicide.
The evaluation of the symptoms of a major depressive episode is especially difficult
when they occur in an indivi dual who also has a general me dical condition (e.g., cancer,
stroke, myocardial infarction, diabetes, pregna ncy). Some of the criterion signs and symp-
toms of a major depressive episode are iden tical to those of general medical conditions
(e.g., weight loss with untreated diabetes; fatigue with cancer; hypersomnia early in preg-
nancy; insomnia later in pregnancy or the postpartum). Such symp toms count toward a
major depressive diagnosis except when they are clearly and fully attributable to a general
medical condition. Nonv egetative symptoms of dysphoria,  anhedonia, guilt or worthless-


ness, impaired concentration or indecision, an d suicidal thoughts should be assessed with
particular care in such cases. Definitions of  major depressive episodes that have been mod-
ified to include only these nonvegetative sympto ms appear to identify nearly the same in-
dividuals as do the full criteria.
Associated Features Supporting Diagnosis
Major depressive disorder is a ssociated with high mortality,  much of which is accounted


dividuals as do the full criteria.
Associated Features Supporting Diagnosis
Major depressive disorder is a ssociated with high mortality,  much of which is accounted
for by suicide; however, it is not the only cause. For example, depressed individuals ad-
mitted to nursing homes have a markedly increased likelihood of death in the first year. In-
dividuals frequently present with tearfulness,  irritability, brooding , obsessive rumination,
anxiety, phobias, excessive worry over physical he alth, and complaints of pain (e.g., head-
aches; joint, abdominal, or other pains). In children, separation anxiety may occur.


Major Depressive Disorder 165
Although an extensive literature exists de scribing neuroanatomi cal, neuroendocrino-
logical, and neurophysiological correlates of major depressive disord er, no laboratory test
has yielded results of sufficient sensitivity and specificity to be used as a diagnostic tool for
this disorder. Until recently, hypothalamic-pit uitary-adrenal axis hyperactivity had been
the most extensively investigated abnormalit y associated with major depressive episodes,
and it appears to be associated with melancho lia, psychotic features, and risks for eventual
suicide. Molecular studies have also implicated peripheral factors, including genetic vari-
ants in neurotrophic factors and pro-inflammatory cytokines. A dditionally, functional
magnetic resonance imaging stud ies provide evidence  for functional ab normalities in spe-
cific neural systems supporting emotion processing, reward seeking, and emotion regula-
tion in adults with major depression.
Prevalence
Twelve-month prevalence of major depressive disorder in the United States is approximately
7%, with marked differences by age group such th at the prevalence in 18- to 29-year-old indi-
viduals is threefold higher than the prevalence in individuals age 60 years or older. Females ex-
perience 1.5- to 3-fold higher rates th an males beginning in early adolescence.
Development and Course
Major depressive disorder may first appear at any age, but the likelihood of onset in-
creases markedly with puberty. In the United States, incidence appears to peak in the 20s;
however, first onset in la te life is not uncommon.
The course of major depressive  disorder is quite variable, such that some individuals
rarely, if ever, experience re mission (a period of 2 or more  months with no symptoms, or


only one or two symptoms to no more than a mild degree), while others experience many
years with few or no symptoms  between discrete episodes. It  is important to distinguish
individuals who present for treatment during an exacerbation of a chronic depressive ill-
ness from those whose symptoms developed recently. Chronicity of depressive symptoms
substantially increases the likelihood of underlying personality, anxiety, and substance
use disorders and decreases the likelihood that  treatment will be followed by full symp-
tom resolution. It is therefore useful to ask individuals presenting with depressive symp-
toms to identify the last period  of at least 2 months during wh ich they were entirely free of
depressive symptoms.
Recovery typically begins within 3 months of onset for two in five individuals with ma-
jor depression and within 1 year for four in five individuals. Recency of onset is a strong
determinant of the likelihood of near-term recovery, and many individuals who have been
depressed only for several months can be expe cted to recover sponta neously. Features as-
sociated with lower recovery rates, other th an current episode duration, include psychotic
features, prominent anxiety, persona lity disorders, and symptom severity.
The risk of recurrence become s progessively lower over time as the duration of re-
mission increases. The risk is higher in in dividuals whose preceding episode was severe,
in younger individuals, and in individuals who have already experienced multiple epi-
sodes. The persistence of even  mild depressive symptoms du ring remission is a powerful
predictor of recurrence.
Many bipolar illnesses begin with one or mo re depressive episodes, and a substantial
proportion of individuals who initially appear to have ma jor depressive disorder will
prove, in time, to instead have a bipolar disorder. This is more likely in individuals with


prove, in time, to instead have a bipolar disorder. This is more likely in individuals with
onset of the illness in adolescence, those with psychotic features, and those with a family
history of bipolar illness. The presence of a “with mixed feat ures” specifier also increases
the risk for future manic or hypomanic diagnosis. Major depr essive disorder, particularly


history of bipolar illness. The presence of a “with mixed feat ures” specifier also increases
the risk for future manic or hypomanic diagnosis. Major depr essive disorder, particularly
with psychotic features, may al so transition into schizophre nia, a change that is much
more frequent than the reverse.


166 Depressive Disorders
Despite consistent differences between gender s in prevalence rates for depressive disor-
ders, there appear to be no clear differences by gender in phenomenology, course, or treat-
ment response. Similarly, there are no clear effe cts of current age on the course or treatment
response of major depressive disorder. Some symptom differe nces exist, though, such that
hypersomnia and hyperphagia ar e more likely in younger individuals, and melancholic
symptoms, particularly psychomotor disturbances, are more common in older individuals.
The likelihood of suicide attempts lessens in mi ddle and late life, although the risk of com-
pleted suicide does not. Depressions with ea rlier ages at onset are more familial and more
likely to involve personality disturbances. The course of major depressive disorder within
individuals does not generally change with aging. Mean times to recovery appear to be sta-
ble over long periods, and the likelihood of be ing in an episode does not generally increase
or decrease with time.
Risk and Prognostic Factors
Temperamental. Neuroticism (negative affectivity) is a well-established risk factor for the
onset of major depressive disorder, and high le vels appear to render individuals more likely
to develop depressive episodes in re sponse to stressful life events.
Environmental. Adverse childhood experiences, part icularly when there are multiple
experiences of diverse types, constitute a set of  potent risk factors for major depressive dis-
order. Stressful life events are well recognized  as precipitants of major depressive epi-
sodes, but the presence or absence of adverse life events near the onset of episodes does
not appear to provide a useful guide to prognosis or treatment selection.
Genetic and physiological. First-degree family members of individuals with major de-


Genetic and physiological. First-degree family members of individuals with major de-
pressive disorder have a risk for major depres sive disorder two- to  fourfold higher than
that of the general population. Relative risks appear to be higher for early-onset and re-
current forms. Heritability is a pproximately 40%, and the personality trait neuroticism ac-
counts for a substantial port ion of this genetic liability.
Course modifiers. Essentially all major nonm ood disorders increase the risk of an indi-
vidual developing depression. Major depressive episodes th at develop against the back-
ground of another disorder of ten follow a more refractory course. Substance use, anxiety,
and borderline personality diso rders are among the most common of these, and the pre-
senting depressive symptoms may obscure an d delay their recognition. However, sus-
tained clinical improvement in depressive  symptoms may depend on the appropriate
treatment of underlying illnesses. Chronic or  disabling medical conditions also increase
risks for major depressive episod es. Such prevalent illnesses as diabetes, morbid obesity,
and cardiovascular disease are often complicated by depressive episodes, and these epi-
sodes are more likely to become chronic than are depressive episodes in medically healthy
individuals.
Culture-Related Diagnostic Issues
Surveys of major depressive disorder across diverse cultures have shown sevenfold dif-
ferences in 12-month prevalen ce rates but much more consistency in female-to-male ratio,
mean ages at onset, and the degree to which presence of the disorder raises the likelihood
of comorbid substance abuse. While these findings suggest substantial cultural differences
in the expression of major depressive disord er, they do not permit simple linkages be-
tween particular cultures and the likelihoo d of specific symptoms. Rather, clinicians


tween particular cultures and the likelihoo d of specific symptoms. Rather, clinicians
should be aware that in most  countries the majority of cases of depression go unrecog-
nized in primary care settings and that in ma ny cultures, somatic sy mptoms are very likely
to constitute the presenting  complaint. Among the Criterion A symptoms, insomnia and
loss of energy are the most uniformly reported.


Major Depressive Disorder 167
Gender-Related Diagnostic Issues
Although the most reproducible finding in th e epidemiology of major depressive disorder
has been a higher prevalence in females, th ere are no clear differences between genders in
symptoms, course, treatment response, or functional consequences. In women, the risk for
suicide attempts is higher, and the risk for suicide completion is lower. The disparity in
suicide rate by gender is not as great among th ose with depressive disorders as it is in the
population as a whole.
Suicide Risk
The possibility of suicidal behavior exists at  all times during major depressive episodes.
The most consistently described risk factor is a past history of suicide attempts or threats,
but it should be remembered that most comp leted suicides are not preceded by unsuccess-
ful attempts. Other features associated with  an increased risk for completed suicide
include male sex, being single or living alone,  and having prominent feelings of hopeless-
ness. The presence of borderline personality disorder markedly increases risk for future
suicide attempts.
Functional Consequences of
Major Depressive Disorder
Many of the functional consequences of major depressive disorder derive from individual
symptoms. Impairment can be very mild, such th at many of those who interact with the af-
fected individual are unaware of depressive symptoms. Impairment may, however, range
to complete incapacity such that the depressed individual is unable to attend to basic self-
care needs or is mute or catatonic. Among individuals seen in ge neral medical settings,
those with major depressive disorder have more pain and physical illness and greater de-
creases in physical, social, and role functioning.
Differential Diagnosis
Manic episodes with irritable mood or mixed episodes. Major depressive episodes
with prominent irritable mood may be difficu lt to distinguish from manic episodes with


with prominent irritable mood may be difficu lt to distinguish from manic episodes with
irritable mood or from mixed episodes. This di stinction requires a careful clinical evalua-
tion of the presence of manic symptoms.
Mood disorder due to another medical condition. A major depressive episode is the
appropriate diagnosis if the mood  disturbance is not judged, based on individual history,
physical examination, and laboratory findings, to be the direct pathophysiological conse-
quence of a specific medical condition (e.g.,  multiple sclerosis, st roke, hypothyroidism).
Substance/medication-induced de pressive or bipolar disorder. This disorder is distin-
guished from major depressive disorder by the fact that a substance (e.g., a drug of abuse,
a medication, a toxin) appears to be etiologically related to the mood disturbance. For ex-
ample, depressed mood that occurs only in the context of withdrawal from cocaine would
be diagnosed as cocaine-induced depressive disorder.
Attention-deficit/hyperactivity disorder. Distractibility and low frustration tolerance
can occur in both attention-deficit/ hypera ctivity disorder and a major depressive epi-
sode; if the criteria are met for both, attention-deficit/hyperactivity disorder may be diag-
nosed in addition to the mood  disorder. However, the clinic ian must be cautious not to
overdiagnose a major depressive episode in ch ildren with attention-deficit/hyperactivity
disorder whose disturbance in mood is characte rized by irritability rather than by sadness
or loss of interest.


168 Depressive Disorders
Adjustment disorder with depressed mood. A major depressive episode that occurs in
response to a psychosocial stressor is distin guished from adjustment  disorder with de-
pressed mood by the fact that the full criteria  for a major depressive episode are not met in
adjustment disorder.
Sadness. Finally, periods of sadness are inhere nt aspects of the human experience.
These periods should not be diagnosed as a major depressive episod e unless criteria are
met for severity (i.e., five out of nine symptoms), duration (i.e., most of the day, nearly ev-
ery day for at least 2 weeks), and clinically significant distress or impairment. The diagno-
sis other specified depressive disorder may be appropriate for presentations of depressed
mood with clinically significant impairment that do not meet criteria  for duration or se-
verity.
Comorbidity
Other disorders with which majo r depressive disorder frequently co-occurs are substance-
related disorders, panic diso rder, obsessive-compulsive diso rder, anorexia nervosa, buli-
mia nervosa, and borderlin e personality disorder.
Persistent Depressive Disorder (Dysthymia)
Diagnostic Criteria 300.4 (F34.1)
This disorder represents a consolidation of  DSM-IV-defined chronic major depressive dis-
order and dysthymic disorder.
A. Depressed mood for most of the day, for more days than not, as indicated by either
subjective account or observation by others, for at least 2 years.
Note:  In children and adolescents, mood can be irritable and duration must be at least
1 year.
B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.


1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individ-
ual has never been without the symptoms in Criteria A and B for more than 2 months at a
time.
D. Criteria for a major depressive disorder may be continuously present for 2 years.
E. There has never been a manic episode or a hypomanic episode, and criteria have
never been met for cyclothymic disorder.
F. The disturbance is not better explained by a persistent schizoaffective disorder,
schizophrenia, delusional disorder, or other specified or unspecified schizophrenia
spectrum and other psychotic disorder.
G. The symptoms are not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition (e.g. hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
Note:  Because the criteria for a major depressive episode include four symptoms that are
absent from the symptom list for persistent depressive disorder (dysthymia), a very limited


Persistent Depressive Disorder (Dysthymia) 169
number of individuals will have depressive symptoms that have persisted longer than 2 years
but will not meet criteria for persistent depressive disorder. If full criteria for a major de-
pressive episode have been met at some point during the current episode of illness, they
should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis of other
specified depressive disorder or unspecified depressive disorder is warranted.
Specify if:
With anxious distress (p. 184)
With mixed features (pp. 184–185)
With melancholic features (p. 185)
With atypical features  (pp. 185–186)
With mood-congruent psychotic features (p. 186)
With mood-incongruent psychotic features  (p. 186)
With peripartum onset  (pp. 186–187)
Specify if:
In partial remission  (p. 188)
In full remission  (p. 188)
Specify if:
Early onset:  If onset is before age 21 years.
Late onset:  If onset is at age 21 years or older.
Specify if (for most recent 2 years of persistent depressive disorder):
With pure dysthymic syndrome:  Full criteria for a major depressive episode have not
been met in at least the preceding 2 years.
With persistent major depressive episode:  Full criteria for a major depressive epi-
sode have been met throughout the preceding 2-year period.
With intermittent major depressi ve episodes, with current episode: Full criteria for
a major depressive episode are currently met, but there have been periods of at least
8 weeks in at least the preceding 2 years with symptoms below the threshold for a full
major depressive episode.


major depressive episode.
With intermittent major depressive episodes, without current episode: Full crite-
ria for a major depressive episode are not currently met, but there has been one or
more major depressive episodes in at least the preceding 2 years.
Specify current severity:
Mild (p. 188)
Moderate  (p. 188)
Severe (p. 188)
Diagnostic Features
The essential feature of persistent depressive disorder (dysthymia) is a depressed mood
that occurs for most of the day, for more days th an not, for at least 2 ye ars, or at least 1 year
for children and adolescents (Criterion A). Th is disorder represents a consolidation of
DSM-IV-defined chronic major depressive di sorder and dysthymic disorder. Major de-
pression may precede persistent depressive disorder, and major de pressive episodes may
occur during persistent depressive disorder. Individuals whose symptoms meet major de-
pressive disorder criter ia for 2 years should be given a diagnosis of persistent depressive
disorder as well as majo r depressive disorder.
Individuals with persistent depressive diso rder describe their mood as sad or “down
in the dumps.” During periods of depressed mood, at least two of the six symptoms from
Criterion B are present. Because these sympto ms have become a part of the individual’s
day-to-day experience, particular ly in the case of early onse t (e.g., “I’ve always been this


170 Depressive Disorders
way”), they may not be reported unless the indi vidual is directly prom pted. During the 2-year
period (1 year for children or adolescents), any symptom-free intervals last no longer than
2 months (Criterion C).
Prevalence
Persistent depressive disorder is effectively an amalgam of DSM-IV dysthymic disorder and
chronic major depressive episode. The 12-month prevalence in the United States is approxi-
mately 0.5% for persistent depre ssive disorder and 1.5% for chro nic major depressive disorder.
Development and Course
Persistent depressive disorder often has an early and insidious onset (i.e., in childhood,
adolescence, or early adult life) and, by de finition, a chronic course. Among individuals
with both persistent depressiv e disorder and borderline pers onality disorder, the covari-
ance of the corresponding features over ti me suggests the operatio n of a common mecha-
nism. Early onset (i.e., before age 21 years)  is associated with a higher likelihood of
comorbid personality disorder s and substance use disorders.
When symptoms rise to the level of a major depressive episode, they are likely to sub-
sequently revert to a lower level. However,  depressive symptoms are much less likely to
resolve in a given period of time in the context of persistent depressive disorder than they
are in a major depressive episode.
Risk and Prognostic Factors
Temperamental. Factors predictive of poorer long -term outcome include higher levels
of neuroticism (negative affect ivity), greater symptom severity, poorer global functioning,
and presence of anxiety disorders or conduct disorder.
Environmental. Childhood risk factors include parental loss or separation.
Genetic and physiological. There are no clear differences in  illness development, course,


Genetic and physiological. There are no clear differences in  illness development, course,
or family history between DSM-IV dysthymi c disorder and chronic major depressive dis-
order. Earlier findings pertaining to either disorder are therefore likely to apply to per-
sistent depressive disorder. It is thus likel y that individuals with persistent depressive
disorder will have a higher pr oportion of first-degree relatives with persistent depressive
disorder than do individuals with major de pressive disorder, and more depressive disor-
ders in general.
A number of brain regions (e.g., prefrontal  cortex, anterior cing ulate, amygdala, hip-
pocampus) have been implicated in persiste nt depressive disorder. Possible polysomno-
graphic abnormalities exist as well.
Functional Consequences of
Persistent Depressive Disorder
The degree to which persistent depressive diso rder impacts social and occupational func-
tioning is likely to vary widely, but effects can be as great as or greater than those of major
depressive disorder.
Differential Diagnosis
Major depressive disorder. If there is a depressed mood plus two or more symptoms
meeting criteria for a persistent depressive ep isode for 2 years or more, then the diagnosis of
persistent depressive disorder is made. Th e diagnosis depends on the 2-year duration,
which distinguishes it from episodes of depressi on that do not last 2 years. If the symptom


Premenstrual Dysphoric Disorder 171
criteria are sufficient for a diagnosis of a major depressive episode at any time during this pe-
riod, then the diagnosis of major depression shou ld be noted, but it is coded not as a separate
diagnosis but rather as a specifie r with the diagnosis of  persistent depressive disorder. If the
individual’s symptoms currently meet full crit eria for a major depressive episode, then the
specifier of “with intermittent major depressi ve episodes, with current episode” would be
made. If the major depressive episode has pers isted for at least a 2-year duration and re-
mains present, then the specifie r “with persistent major depressive episode” is used. When
full major depressive episode cr iteria are not currently met but there has been at least one
previous episode of major depression in the cont ext of at least 2 years of persistent depres-
sive symptoms, then the specifier of “with in termittent major depres sive episodes, without
current episode” is used. If the individual ha s not experienced an episode of major depres-
sion in the last 2 years, then the specifier “with pure dysthymic syndrome” is used.
Psychotic disorders. Depressive symptoms are a common  associated feature of chronic
psychotic disorders (e.g., schi zoaffective disorder, schizophrenia, delusional disorder). A
separate diagnosis of persistent depressive disorder is not made if the symptoms occur
only during the course of the psychoti c disorder (including residual phases).
Depressive or bipolar and related diso rder due to another medical condition. Persistent
depressive disorder must be distinguished from a depressive or bipolar and related dis-
order due to another medical co ndition. The diagnosis is depressive or bipolar and related


order due to another medical co ndition. The diagnosis is depressive or bipolar and related
disorder due to another medical condition if the mood disturbance is judged, based on his-
tory, physical examination, or laboratory findin gs, to be attributable to the direct patho-
physiological effects of a specific, usually  chronic, medical condition (e.g., multiple
sclerosis). If it is judged that the depressive  symptoms are not attrib utable to the physiolog-
ical effects of another medical condition, then the primary ment al disorder (e.g., persistent
depressive disorder) is recorded, and the medi cal condition is noted as a concomitant med-
ical condition (e.g., diabetes mellitus).
Substance/medication-induced depressive or bipolar disorder. A substance/medi-
cation-induced depressive or bipolar and rela ted disorder is distin guished from persis-
tent depressive disorder when a substance (e.g ., a drug of abuse, a medication, a toxin) is
judged to be etiologically re lated to the mood disturbance.
Personality disorders. Often, there is evidence of a co existing personality disturbance.
When an individual’s presentation meets the cr iteria for both persis tent depressive disor-
der and a personality disorder , both diagnoses are given.
Comorbidity
In comparison to individuals with major depressive disorder, those with persistent de-
pressive disorder are at higher risk for psychiatric comorbidit y in general, and for anxiety
disorders and substance use disorders in partic ular. Early-onset persistent depressive dis-
order is strongly associated with DSM-IV  Cluster B and C personality disorders.
Premenstrual Dysphoric Disorder
Diagnostic Criteria 625.4 (N94.3)
A. In the majority of menstrual cycles, at least five symptoms must be present in the final


A. In the majority of menstrual cycles, at least five symptoms must be present in the final
week before the onset of menses, start to improve  within a few days after the onset of
menses, and become minimal  or absent in the week postmenses.
B. One (or more) of the following symptoms must be present:
1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or in-
creased sensitivity to rejection).