Mood Disorders in DSM-5

JAN FAWCETT, M.D. Department of Psychiatry University of New Mexico School of Medicine

Mood Disorders Workgroup

William Coryell, MD head of bipolar subworkgroup Lori Davis, MD Raymond DePaulo, MD associate chair Jan Fawcett, MD chair Ellen Frank, PhD - editor of final submitted drafts Sir David Goldberg MD head of anxiety subworkgroup James Jackson, PhD Kenneth Kendler, MD moved to SRC Mario Maj, MD - moved to ICD-11 Michael Phillips, MD, MPH Trish Suppes, MD, PhD head of bipolar subworkgroup Carlos Zarate, MD

Liaisons to Mood Workgroup

Kimberly Yonkers, MD *** Gender/Cross Culture chair, PMDD subworkgroup David Schaffer, MD Child Adolescent *** Ellen Leibenluft, MD *** Rachel Klein, PhD Daniel Pine, MD *** Renato Alercon, MD Personality John Oldham, MD Juan Bustillo, MD Psychotic Disorders Hans - Ulrich Witchen, Ph D Anxiety Disorders *** -Made specific contributions to Workgroup

Advisors
*** Sidney Zisook, M.D. bereavement exclusion Morton Silverman, M.D. suicide assessment Ken Jobes PhD suicide assessment Alan Swann, M.D. mixed specifier Norman Rosenthal, MD. - seasonal affective disorder ***Jules Angst M.D. bipolar disorder, originally a Work Group member Other informal advisors *** - made specific contributions to Workgroup

Summary of Changes: Depressive Disorders- New Diagnoses

New Diagnosis: Dysruptive Mood Dysregulation Disorder (DMDD) Made over 6/under 18 - verbal or behavioral angry outbursts, out of proportion, 3 or more times weekly with general irritable mood most of the time for at least 12 months, with no three month period free of episodes - an alternative to Bipolar Specified or Unspecified (Bipolar NOS).

Disruptive Mood Dysregulation Disorder - Criteria

A. Severe recurrent temper outbursts, manifesting verbally (e,g, verbal rages) and/or behaviorally (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 incondsistent with developmental level. C. The temper outbursts occur, on average, 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).

Disruptive Mood Dysregulation Disorder (contd - 2)

E. Criteria A-D have been present for 12 or more months.Throughout that time, the individual has not had a period 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 befoore age 6 years or after the age 18 years. H. By history or observation, the age of onset of Criteria A-Eis before 10 years.

Disruptive Mood Dysregulation Disorder (contd-3)

I. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode, have been met. J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not explsined by another mental disorder (e.g. autism spectrum disorder, post-traumatic stress disorder, separation anxiety disorder, persistent depressive disorder (dysthymia) Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, attention deficit/hyperactivity disorder, coduct disorder, and substance abuse disordera. Individuals whose symptoms meet criteriaa for both disruptive mood dysregualation disorder(DMDD) and oppositional defiant disorder should only be given the diagnosis of DMDD. If the individual has ever experienced a hypomanic episode, the diagnosis of DMDD should not be assigned. K. The symptoms are not attributable to the physiological effects of a substance or another medial or neurological condition.

Some Comments on the Source of DMDD

Dickstein DP and Liebenluft E 2012, Is J Psychiatry Rel Sci Significant increase in diagnosis of BD in children and adolescents ambiguity in criteria and how they aply to children with functionally impairint irritability. Stringaris A et al, 2012 Am J Psychiatry genetic and phenotypic of irritability with depression Thomas LA et al 2012, Am J Psychiatry Differences in neural and amygdala activity to facial expressions that show differences in SMD ( now DMDD), BD and controls. Towbin K et al. 2013, J Am Child Adolesc Psychiatry SMD (DMDD) impairing, chronic irritability without manic episodes. SMD not at high risk for BD with age.

Peristent Depressive Disorder

Consolidation of Dysthymia, and Chronic Major Depression. Criteria One or two of the following: 1. Poor appetite or over-eating 2. Insomia or hypersomnia 3. Low energy or fatigue 4. Low self-eateem 5. Poor concentration or difficulty making decisions 6. Feelings of hopelessness Duration of symptoms trump number of symptoms Patient cannot reliably remember number of symptoms over two years duration No long considered a less severe form of depressive disorder

Depressive Disorders New Diagnoses Premenstrual Dysphoric Disorder

Criteria A: in the majority of menstrual cycles at least 5 of symptoms must be present in the final week before menses, improve at cessation of menses, and be diminished or absent the week after menses. Criteria B: One or more: 1.Marked affective lability 2. Marked irritability 3. Marked depression, hopelessness or self depreciation 4. Marked anxiety, tension, feeling keyed up or on edge. Criteria C: One or more to reach a total of five symptoms: 1.Decreased interest 2. Lethargy 3. Decreased concentration 4. Marked change in appetite 5.Sleep disturbance 6. Feeling overwhelmed/ out of control 7. Physical symptoms tender or swelling breasts, muscle pain, bloating, weight gain. Symptoms must have occurred most of periods past year, be significantly distressing, not an exacerbation of a present disorder, be measured by ratings of at least 2 prior symptomatic cycles.

Some Background on the Genesis of DMDD

Dickstein DP, Leibenluft E, 2012 Is J Psychaitry Rel Sci- From the mid 1990s to present significant rise in diagnosis of BD in children & adolesents. Why? ambiguity in diagnostic criteria for mania and how they apply to children with functionally impairing irritability. Stringaris A et al, A J Psychiatry 2012 Adolescent irritability: phenotypic associations and genetic links with depressed mood. Thomas LA et al, Arch Gen Psychiatry 2012 BD and SMD differ in amygdala modifications from NHV and each other. Towbin K et al 2013, J Am Acad Adolesc Paychiatry literature review

Summary of Changes in Depressive Disorders

Major Depressive Episode drop bereavement exclusion. Major Depressive Episode addition of mixed specifier. Major Depressive Episode addition of anxiety dimension Depressive Disorder NOS change to specified and unspecified Post-partum Depression specifier changed to Peri-Partum Depression Specifier

Note on Grief vs. MDE

A note distinguishing grief from MDE discussing grief manifested by a preoccupation with the loss, grief pangs associated with reminders of the deceased, with a capability for humor/ enjoyment returning as opposed fo MDE with peristent anhedonia, guilt, low self esteem and self worth, and thoughts of suicide - appears in DSM-5. In dropping the bereavement exclusion, this differentiation is left for the clinicians decision.

Post- Partum Depression changed to Peri-Partum Depression Specifier

In DSM-5 change Post Partum Depression to a Peri-Partum Depression specifier to reflect that an MDE can occur during pregnancy as well as after partuition. MDE still must occur within 4 weeks of partuition to qualify for Peri-Partum Depression specifier.

Changes in Bipolar and Related Disorders

Drop Bipolar I, mixed state and substitute specifier of mixed type across all bipolar disorders (including Bipolar II disorder and Major Depressive Episode) Add and energy or increased goal directed activity to Criterion A for Bipolar I and Bipolar II disorder. Add addition of anxiety severity specifier to all bipolar diagnoses. Change Bipolar Disorder NOS to Bipolar Disorder, Specified or Unspecified. Mania/hypomania after treatment with medications (including ADM ) lasting beyond the time physiological effects of the drug, may be diagnosed as a bipolar disorder.

Specified vs. Unspecified Mood Diagnoses

Other Specified Depressive Disorder Three types: 1. Recurrent Brief Depression: Depressed mood plus four other symptoms lasting 2-13 days occurring monthly for at least 12 months. 2. Short Duration Depression - 5/9 criteria symptoms for 4-13 days. 3. Depressive Episode with insufficient symptoms Depressive mood plus one other symptom with clinically significant distress or impairment. Unspecified Depressive Disorder Insufficient information but clinician suspects depressive disorder with clinically significant distress or impairment. e.g. emergency room diagnosis

The Mixed Specifier Across All Mood Disorders - MDE

Depressive Episode with Mixed Features: Full MDE criteria, at least 3 symptoms for majority of days of current/most recent episode. At Least 3 of the following: 1. Elevated, expansive mood 2. Inflated self esteem/grandiosity 3. More talkative/pressured speech 4. Flight of ideas/racing thoughts 5. Increased energy/goal directed behavior 6. Increased involvement in activities with a potential for painful consequences 7. Decreased need for sleep Obsevable by others/ a change from usual behavior

 Meets full criteria for manic/hypomanic episode and has at least 3 of symptoms for the majority of days of epidode. Symptoms: 1. Prominent dysphoric or depressed mood 2. Diminished interest and pleasure in all or almost all activities 3. Psychomotor retardation nearly every day 4. Fatigue/loss of energy 5. Feelings of worthlessness, inappropriate guilt 6. Recurrent thoughts of death, suicidal ideation, attempts or suicide plan Symptoms observed by others. A change from usual behavior.

Mixed Features in Mania/Hypomania/Unspecified Bipolar Disorder

The Anxiety Severity Specifier Across All Mood Disorders

Specify With Anxious Distress two or more symptoms. Anxious Symptoms: 1. Keyed up/tense 2. Unusually restless 3. Difficulty concentrating because of worry 4. Fear that something awful may happen 5. Feeling of losing control of self Anxiety Severity Mild 2 symptoms Moderate 3 Moderate Severe 4 Severe 4-5 with motor agitation

Strengths and Limitations of the DSM5 Process

Changes had to be approved by the Scientific Review Committee (SRC) or Clinical Public Health Committee (CPHC) to be included in DSM-5 Advantage: Changes required scientific support Disadvantage: If inadequate research was available- no change could be made. Process was bottom up until the last month.