Title psych-trans-1-2-depressive-disorders.pdf ✅

Page 1 of 11 PSYCHIATRY 2 Depressive Disorders Dr. Los Banos 1.2 June 26, 2014 Bautista, Cruz, Gillera, Janolo, Merilles OUTLINE I. Disruptive Mood Dysregulation Disorder II. Major Depressive Disorder III. Persistent Depressive Disorder IV. Premenstrual Dysphoric Disorder V. Substance/ Medication Induced Depressive Disorder VI. Depressive Disorder Due to Another Medical Condition VII. Other Specified Depressive Disorder VIII. Unspecified Depressive Disorder IX. Specifiers for Depressive Disorder DISRUPTIVE MOOD DYSREGULATION DISORDER DIAGNOSTIC CRITERIA A. Severe recurrent temper outbursts manifested 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 inconsistent 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). E. Criteria A-D have been present for 12 or more months. Throughout that time, the individual 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, for a manic or hypomanie 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 mania 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 disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]). Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity 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 experienced a manic or hypomanie 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 another medical or neurological condition. DIAGNOSTIC FEATURES  The core feature of disruptive mood dysregulation disorder is chronic, severe persistent irritability. This has two prominent clinical manifestations: o Frequent temper outbursts  These outbursts typically occur in response to frustration and can be verbal or behavioral (the latter in the form of aggression against property, self, or others).  They must occur frequently (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 they must be developmentally inappropriate (Criterion B). o Chronic, persistently irritable or angry mood  This must be present between the severe temper outbursts.  This irritable or angry mood must be characteristic of the child, being present most of the day, nearly every day, and noticeable by others in the child's environment (Criterion D).  The clinical presentation of disruptive mood dysregulation disorder must be carefully distinguished from presentations of other, related conditions, particularly pediatric bipolar disorder. o Some researchers view severe, non-episodic irritability as characteristic of bipolar disorder 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 disorder. o In DSM-5:  The term bipolar disorder is explicitly reserved for episodic presentations of bipolar symptoms  Disruptive mood dysregulation disorder, provides a distinct category to capture youths whose hallmark symptoms consisted of very severe, nonepisodic irritability. PREVALENCE  Disruptive mood dysregulation disorder is common among children presenting to pediatric mental health clinics.  Based on rates of chronic and severe persistent irritability, which is the core feature of the disorder, the overall 6-month to 1-year period-prevalence of disruptive mood dysregulation disorder among children and adolescents probably falls in the 2%-5% range o 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 disorder must be before age 10 years, and the diagnosis should not be applied to children with a developmental age of less than 6 years. o Because the symptoms of disruptive mood dysregulation disorder are likely to change as children mature, use of the diagnosis should be restricted to age groups similar to those in which validity has been established (7-18 years). o Approximately half of children with severe, chronic irritability will have a presentation that continues to meet criteria for the condition 1 year later.  Rates of conversion from severe, nonepisodic irritability to bipolar disorder are very low. o Children with chronic irritability are at risk to develop unipolar depressive and/or anxiety disorders in adulthood.  Age-related Variations between Classic Bipolar Disorder and Disruptive Mood Dysregulation Disorder: o Rates of bipolar disorder generally are very low prior to adolescence (<1%), with a steady increase into early adulthood (l%-2% prevalence). o Disruptive mood dysregulation disorder is more common than bipolar disorder prior to adolescence, and symptoms of the condition generally become less common as children transition into adulthood. RISK AND PROGNOSTIC FACTORS  Temperamental o Children with chronic irritability typically exhibit complicated psychiatric histories.  Extensive history of chronic irritability is common, typically manifesting before full criteria for the syndrome are met.
Page 2 of 11 PSYCHIATRY 2 Depressive Disorders 1.1 June 26, 2014 Bautista, Cruz, Gillera, Janolo, Merilles  Their prediagnostic presentations may have qualified for a diagnosis of: oppositional defiant disorder, attention-deficit/hyperactivity disorder (ADHD), anxiety disorder, and major depressive disorder  Genetic and physiological o It has been suggested that children presenting with chronic, non-episodic irritability can be differentiated from children with bipolar disorder in their family-based risk.  However, these two groups do not differ in familial rates of anxiety disorders, unipolar depressive disorders, or substance abuse. o Those with disruptive mood dysregulation disorder exhibit both commonalities and differences in information-processing deficits as with those having pediatric bipolar disorder. GENDER-RELATED DIAGNOSTIC ISSUES  Children presenting to clinics with features of disruptive mood dysregulation disorder are predominantly male. o This difference in prevalence between males and females differentiates disruptive mood dysregulation disorder from bipolar disorder, in which there is an equal gender prevalence. SUICIDE RISK  In general, evidence documenting suicidal behavior and aggression, as well as other severe functional consequences, in disruptive mood dysregulation disorder should be noted when evaluating children with chronic irritability. FUNCTIONAL CONSEQUENCES OF DISRUPTIVE MOOD DYSREGULATION DISORDER  Chronic, severe irritability is associated with marked disruption in a child's family and peer relationships, as well as in school performance. o Because of their extremely low frustration tolerance, such children generally have difficulty succeeding in school; they are often unable to participate in the activities typically enjoyed by healthy children o Their family life is severely disrupted by their outbursts and irritability; and they have trouble initiating or sustaining friendships.  Levels of dysfunction in children with bipolar disorder and disruptive mood dysregulation disorder are generally comparable o Dangerous behavior, suicidal ideation or suicide attempts, severe aggression, and psychiatric hospitalization are common. DIFFERENTIAL DIAGNOSIS  Because chronically irritable children and adolescents typically present with complex histories, the diagnosis of disruptive mood dysregulation disorder must be made while considering the presence or absence of multiple other conditions. BIPOLAR DISORDERS  Bipolar I disorder and bipolar II disorder manifest as an episodic illness with discrete episodes of mood perturbation that can be differentiated from the child's typical presentation.  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-directed activity), which are also present to a degree that is distinctly different from the child's usual baseline  The central feature differentiating disruptive mood dysregulation disorder and bipolar disorders in children involves the longitudinal course of the core symptoms  In Bipolar disorder, there is distinct time period (episodic) during which the child's mood and behavior were markedly different from usual.  In contrast, the irritability of disruptive mood dysregulation disorder is persistent and is present over many months; while it may wax and wane to a certain degree, severe irritability is characteristic of the child with disruptive mood dysregulation disorder.  Disuptive Mood Dysregulation Disorder does not manifest full-duration or episodic manic (irritable or euphoric) lasting more than 1 day. Elevated mood and grandiosity does not occur. OPPOSITIONAL DEFIANT DISORDER  The key features that warrant the diagnosis of disruptive mood dysregulation disorder in children whose symptoms also meet criteria for oppositional defiant disorder are the presence of severe and frequently recurrent outbursts and a persistent disruption in mood between outbursts ( severe impairment in at least one setting (i.e., home, school, or among peers) and mild to moderate impairment in a second setting.  Most children whose symptoms meet criteria for disruptive mood dysregulation disorder will also have a presentation that meets criteria for oppositional defiant disorder, but the reverse is not the case.  More prominent mood component among individuals with disruptive mood dysregulation disorder, as compared with individuals with oppositional defiant disorder. ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER, MAJOR DEPRESSIVE DISORDER, ANXIETY DISORDERS, AUTISM SPECTRUM DISORDER  Unlike children diagnosed with bipolar disorder or oppositional defiant disorder, a child whose symptoms meet criteria for disruptive mood dysregulation disorder also can receive a comorbid 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) should receive a diagnosis of major depressive disorder rather than disruptive mood dysregulation disorder.  Children whose irritability is manifest only in the context of exacerbation of an anxiety disorder should receive the relevant anxiety disorder diagnosis rather than disruptive mood dysregulation disorder.  Children with autism spectrum disorders frequently present with temper outbursts when, for example, their routines are disturbed. This should be considered secondary to the autism spectrum disorder. INTERMITTENT EXPLOSIVE DISORDER  Children with symptoms suggestive of intermittent explosive disorder present with instances of severe temper outbursts, much like children with disruptive mood dysregulation disorder.  However, unlike disruptive mood dysregulation disorder, intermittent explosive disorder does not require 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 dysregulation disorder. COMORBIDITY  Rates of comorbidity in disruptive mood dysregulation disorder are extremely high.  The strongest overlap is with oppositional defiant disorder  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 disorder should be assigned.  The diagnosis of disruptive mood dysregulation disorder should not be assigned if the symptoms occur only in an anxiety provoking context, when the routines of a child with autism spectrum disorder or obsessive-compulsive disorder
Page 3 of 11 PSYCHIATRY 2 Depressive Disorders 1.1 June 26, 2014 Bautista, Cruz, Gillera, Janolo, Merilles are disturbed, or in the context of a major depressive episode. MAJOR DEPRESSIVE DISORDER DIAGNOSTIC CRITERIA 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 subjective 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 all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3) Significant weight loss when not dieting or weight gain (e.g., a change of more than5% of body weight in a month), or decrease 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, notmerely 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 delusional)nearly every day (not merely self-reproach or guilt about being sick). 8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (eitherby subjective account or as observed by others). 9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation withouta specific plan, or a suicide attempt or a specific plan for committing suicide. CRITERIA B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. CRITERIA 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 natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, 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 understandable 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 exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss. CRITERIA D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. CRITERIA 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 medical condition. Specify: With anxious distress With mixed features With melancholic features With atypical features With mood-congruent psychotic features With mood-incongruent psychotic features With catatonia With peripartum onset With seasonal pattern (recurrent episode only) DIAGNOSTIC FEATURES  The criterion symptoms for major depressive disorder must be present nearly every day tobe considered present, with the exception of weight change and suicidal ideation.  Depressedmood must be present for most of the day, in addition to being present nearly every day.  Often insomnia or fatigue is the presenting complaint, and failure to probe foraccompanying depressive symptoms will result in under diagnosis.  Sadness may be deniedat first but may be elicited through interview or inferred from facial expression anddemeanor.  Clinicians should determinewhether the distress from that complaint is associated with specific depressivesymptoms.  Fatigue and sleep disturbance are present in a high proportion of cases  Psychomotordisturbances are much less common but are indicative of greater overall severity  Presence of delusional or near-delusional guilt- also an indicator of overall severity ASSOCIATEED FEATURES SUPPORTING DIAGNOSIS  Associated with high mortality: o Suicide o Depressed individuals admittedto nursing homes have a markedly increased likelihood of death in the first year.  Individualsfrequently present with tearfulness, irritability, brooding, obsessive rumination,anxiety, phobias, and excessive worry over physical health, and complaints of pain.  In children, separation anxiety may occur. PREVALENCE  Prevalence in 18- to 29-year-old individualsis threefold higher than the prevalence in individuals aged 60 years or older.  Females experience1.5- to 3-fold higher rates than males beginning in early adolescence. DEVELOPMENT AND COURSE  Major depressive disorder may first appear at any age, but the likelihood of onset increasesmarkedly with puberty.  The course of major depressive disorder is variable, some individuals experience remission o period of 2 or more months with no symptoms, oronly one or two symptoms to no more than a mild degree o Others experience manyyears with few or no symptoms between discrete episodes. It is important to distinguish  It is important to distinguish individuals who present for treatment during an exacerbation of a chronic depressive illnessfrom those whose symptoms developed recently.  Recovery typically begins within 3 months of onset for two in five individuals with majordepression and within 1 year for four in five individuals.  Recency of onset is a strongdeterminant of the likelihood of near-term recover  Features associated with lower recovery rates include: o Psychoticfeatures o prominent anxiety o personality disorders o symptom severity  The risk of recurrence becomes progessively lower over time as the duration of remissionincreases.  The persistence of even mild depressive symptoms during remission is a powerfulpredictor of recurrence.  Many bipolar illnesses begin with one or more depressive episodes
Page 4 of 11 PSYCHIATRY 2 Depressive Disorders 1.1 June 26, 2014 Bautista, Cruz, Gillera, Janolo, Merilles  Major depressive disorder, particularlywith psychotic features, may also transition into schizophrenia, a change that is muchmore frequent than the reverse.  Hypersomnia and hyperphagia are more likely in younger individuals, and melancholic symptoms are more common in older individuals.  The likelihood of suicide attempts lessens in middle and late life, although the risk of completedsuicide does not. RISK AND PROGNOSTIC FACTORS  Temperamental o Neuroticism (negative affectivity) is a well-established risk factor for theonset of major depressive disorder, and high levels appear to develop depressive episodes in response to stressful life events.  Environmental o Stressful life events are well recognized as precipitants of major depressive episodes  Genetic and physiological o First-degree family members of individuals with major depressivedisorder have a risk for major depressive disorder two- to fourfold higher than the general population. o Heritability is approximately 40%  Course modifiers o Essentially all major nonmood disorders increase the risk of an individualdeveloping depression. o Chronic or disabling medical conditions also increaserisks for major depressive episodes. o Such prevalent illnesses as diabetes, morbid obesity,and cardiovascular disease are often complicated by depressive episodes, and these episodesare more likely to become chronic than are depressive episodes in medically healthyindividuals. SUICIDE RISK  The possibility of suicidal behavior exists at all times during major depressive episodes.  Other features associated with an increased risk for completed suicideinclude: o male sex o being single or living alone o having prominent feelings of hopelessness.  The presence of borderline personality disorder markedly increases risk for futuresuicide attempts. FUNCTIONAL CONSEQUENCES OF MAJOR DEPRESSIVE DISORDER  Impairment may range from mild to complete incapacity such that the depressed individual is unable to attend to basic selfcareneeds or is mute or catatonic. DIFFERENTIAL DIAGNOSIS Manic episodes with irritable mood or mixed episodes.  Major depressive episodeswith prominent irritable mood may be difficult to distinguish from manic episodes withirritable mood or from mixed episodes. This distinction requires a careful clinical evaluationof 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 judgedto be the direct pathophysiological consequenceof a specific medical condition Substance/medication-induced depressive or bipolar disorder.  This disorder is distinguished from major depressive disorder by the fact that a substance appears to be etiologically related to the mood disturbance. Attention-deficit/hyperactivity disorder.  Distractibility and low frustration tolerance can occur in both attention-deficit/ hyperactivity disorder and a major depressive episode Adjustment disorder with depressed mood.  A major depressive episode that occurs in response to a psychosocial stressor is distinguished from adjustment disorder with depressed mood by the fact that the full criteria for a major depressive episode are not met in adjustment disorder. Sadness.  Periods of sadness are inherent aspects of the human experience.  These periods should not be diagnosed as a major depressive episode unless criteria aremet for severity, duration, and clinically significant distress or impairment. COMORBIDITY  Substancerelateddisorders  Panic Disorder  Obsessive-compulsive disorder  Anorexia nervosa  Bulimia nervosa  Borderline personality disorder. PERSISTENT DEPRESSIVE DISORDER DIAGNOSTIC CRITERIA 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 east 1 year. B. Presence, while depressed of two (or more) of the following: 1. Poor appetite 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 individual 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 hypomaniac 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 or another medical condition. 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 number of individuals will have depressive symptoms that have persisted longer than 2 years but will not meet the criteria for persistent depressive disorder. If full criteria for a major depressive 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 or unspecified depressive disorder is warranted. Specify if: With anxious distress With mixed features With melancholic features With atypical features With mood-congruent psychotic features With mod-incongruent psychotic features With peripartum onset