Mood Disorders Old

Mood Disorders

The Mood Disorders section includes disorders

that have a disturbance in mood as the
predominant feature. The section is divided into
three parts.
The first part describes
mood episodes (Major Depressive Episode,
Manic Episode, Mixed Episode, and Hypomanic
Episode) that have been included separately at
the beginning of this section for convenience in
diagnosing the various Mood Disorders. These
episodes do not have their own diagnostic codes
and cannot be diagnosed as separate entities;
however, they
serve as the building blocks for the disorder
diagnoses.
The second part describes the
Mood Disorders (e.g., Major Depressive
Disorder, Dysthymic Disorder, Bipolar I
Disorder). The criteria sets for most of the Mood
Disorders require the presence or absence of the
mood episodes described in the first part of the
section.
The third part
includes the specifiers that describe either the
most recent mood episode or the course of
recurrent episodes.
The Mood Disorders are divided into

the Depressive Disorders ("unipolar
depression"),
the Bipolar Disorders, and two disorders
based on etiologyMood Disorder Due to a
General Medical Condition and Substance-
Induced Mood Disorder.
The Depressive Disorders (i.e., Major
Depressive Disorder, Dysthymic Disorder, and
Depressive Disorder Not Otherwise Specified)
are distinguished from the Bipolar
Disorders by the fact that there is no history of
ever having had a Manic, Mixed, or Hypomanic
Episode.
 The Bipolar Disorders (i.e., Bipolar I
Disorder,
 Bipolar II Disorder,
 Cyclothymic Disorder, and Bipolar Disorder
Not Otherwise Specified) involve the
presence (or history) of Manic Episodes,
Mixed Episodes, or Hypomanic Episodes,
usually accompanied by the presence (or
history) of Major Depressive Episodes.
o Major Depressive Disorder is characterized

by one or more Major Depressive
Episodes (i.e., at least 2 weeks of depressed
mood or loss of interest accompanied by at
least four additional symptoms of depression).
o Dysthymic Disorder is characterized by at

least 2 years of depressed mood for more
days than not, accompanied by additional
depressive symptoms that do not meet
criteria for a Major Depressive Episode.
o Depressive Disorder Not Otherwise
Specified is included for coding disordersn
with depressive features that do not meet
criteria for Major Depressive Disorder,
Dysthymic Disorder, Adjustment Disorder
With Depressed Mood, or Adjustment
Disorder With Mixed Anxiety and
Depressed Mood (or depressive symptoms
about which there is inadequate or
contradictory information).
 Bipolar I Disorder is characterized by one or

more Manic or Mixed Episodes, usually
accompanied by Major Depressive
Episodes.
 Bipolar II Disorder is characterized by one

or more Major Depressive Episode
accompanied by at least one Hypomanic
Episode.
 Cyclothymic Disorder is characterized by at
least 2 years of numerous periods of
hypomanic symptoms that do not meet criteria
for a Manic Episode and numerous
periods of depressive symptoms that do not meet
criteria for a Major Depressive
Episode.
 Bipolar Disorder Not Otherwise Specified is

included for coding disorders with
bipolar features that do not meet criteria for any
of the specific Bipolar Disorders defined
in this section (or bipolar symptoms about which
there is inadequate or contradictory
information).
 Mood Disorder Due to a General Medical

Condition is characterized by a
prominent and persistent disturbance in mood
that is judged to be a direct physiological
consequence of a general medical condition.
 Substance-Induced Mood Disorder is
characterized by a prominent and persistent
disturbance in mood that is judged to be a direct
physiological consequence of a drug of
abuse, a medication, another somatic treatment
for depression, or toxin exposure.
 Mood Disorder Not Otherwise Specified is

included for coding disorders with mood
symptoms that do not meet the criteria for
any specific Mood Disorder and in which it
is difficult to choose between Depressive
Disorder Not Otherwise Specified and
Bipolar Disorder Not Otherwise Specified
(e.g., acute agitation).
The specifiers described in the third part of the

section are provided to increase
diagnostic specificity, create more homogeneous
subgroups, assist in treatment
selection, and improve the prediction of
prognosis. Some of the specifiers describe the
clinical status of the current (or most recent)
mood episode (i.e.,
Severity/Psychotic/Remission Specifiers),
whereas others describe features of the
current episode (or most recent episode if the
episode is currently in partial or full
remission) (i.e., Chronic, With Catatonic
Features, With Melancholic Features, With
Atypical Features, With Postpartum Onset).
Table 1 (See linked section) indicates
which episode specifiers apply to each codable
Mood Disorder. Other specifiers describe
the course of recurrent mood episodes (i.e.,
Longitudinal Course Specifiers, With
Seasonal Pattern, With Rapid Cycling). Table 2
(See linked section) indicates which
course specifiers apply to each codable Mood
Disorder. The specifiers that indicate
severity, remission, and psychotic features can
be coded in the fifth digit of the
diagnostic code for most of the Mood Disorders.
The other specifiers cannot be coded.
The Mood Disorders section is organized as
follows:
· Mood Episodes
Major Depressive Episode (See linked section)
Manic Episode (See linked section)
Mixed Episode (See linked section)
Hypomanic Episode (See linked section)
· Depressive Disorders
296.xx Major Depressive Disorder (See linked
section)
300.4 Dysthymic Disorder (See linked
section)
311 Depressive Disorder Not Otherwise
Specified (See linked
section)
· Bipolar Disorders
296.xx Bipolar I Disorder (See linked section)
296.89 Bipolar II Disorder (See linked section)
301.13 Cyclothymic Disorder (See linked
section)
296.80 Bipolar Disorder Not Otherwise
Specified (See linked section)
· Other Mood Disorders
293.83 Mood Disorder Due to . . . [Indicate the
General Medical
Condition] (See linked section)
29x.xx Substance-Induced Mood Disorder (See
linked section)
296.90 Mood Disorder Not Otherwise Specified
(See linked section)
· Specifiers describing the clinical status of
the current (or most recent) mood
episode
Mild, Moderate, Severe Without Psychotic

Features, Severe With Psychotic
Features, In Partial Remission, In Full
Remission (for Major Depressive
Episode, See linked section; for Manic Episode,
See linked section; for
Mixed Episode, See linked section)
· Specifiers describing features of the current
episode (or most recent
episode if currently in partial or full remission)
Chronic (See linked section)
With Catatonic Features (See linked section)
With Melancholic Features (See linked section)
With Atypical Features (See linked section)
With Postpartum Onset (See linked section)
· Specifiers describing course of recurrent
episodes
Longitudinal Course Specifiers (With or
Without Full Interepisode
Recovery) (See linked section)
With Seasonal Pattern (See linked section)
With Rapid Cycling (See linked section)
Recording Procedures for Major Depressive

Disorder and
Bipolar I and Bipolar II Disorders
Selecting diagnostic codes. The diagnostic

codes are selected as follows:
For Major Depressive Disorder:
1. The first three digits are 296.
2. The fourth digit is either 2 (if there is only a
single Major Depressive Episode)
or 3 (if there are recurrent Major Depressive
Episodes).
3. The fifth digit indicates the severity of the
current Major Depressive Episode if
full criteria are met as follows: 1 for Mild
severity, 2 for Moderate severity, 3 for
Severe Without Psychotic Features, 4 for Severe
With Psychotic Features. If full
criteria are not currently met for a Major
Depressive Episode, the fifth digit
indicates the current clinical status of the Major
Depressive Disorder as follows:
5 for In Partial Remission, 6 for In Full
Remission. If current severity or clinical
status is unspecified, the fifth digit is 0.
For Bipolar I Disorder:

1. The first three digits are also .
2. The fourth digit is 0 if there is a single Manic
Episode. For recurrent episodes,
the fourth digit indicates the nature of the
current episode (or, if the Bipolar I
Disorder is currently in partial or full remission,
the nature of the most recent
episode) as follows: 4 if the current or most
recent episode is a Hypomanic
Episode or a Manic Episode, 6 if it is a Mixed
Episode, 5 if it is a Major
Depressive Episode, and 7 if the current or most
recent episode is Unspecified.
3. The fifth digit (except for Bipolar I Disorder,
Most Recent Episode Hypomanic,
and Bipolar I Disorder, Most Recent Episode
Unspecified) indicates the severity
of the current episode if full criteria are met for a
Manic, Mixed, or Major
Depressive Episode as follows: 1 for Mild
criteria are not met for a Manic, Mixed, or Major
Depressive Episode, the fifth
digit indicates the current clinical status of the
Bipolar I Disorder as follows: 5 for
In Partial Remission, 6 for In Full Remission. If
current severity or clinical status
is unspecified, the fifth digit is 0. For Bipolar I
Disorder, Most Recent Episode
Hypomanic, the fifth digit is always 0. For
Bipolar Disorder, Most Recent
Episode Unspecified, there is no fifth digit.
For Bipolar II Disorder, the diagnostic code is
296.89.
Recording the name of the diagnosis. In

recording the name of a diagnosis, terms
should be listed in the following order:
1. Name of disorder (e.g., Major Depressive
Disorder, Bipolar Disorder)
2. Specifiers coded in the fourth digit (e.g.,

Recurrent, Most Recent Episode Manic)
3. Specifiers coded in the fifth digit (e.g., Mild,

Severe With Psychotic Features, In
Partial Remission)
4. As many specifiers (without codes) as apply

to the current or most recent episode
(e.g., With Melancholic Features, With
Postpartum Onset)
5. As many specifiers (without codes) as apply

to the course of recurrent episodes
(e.g., With Seasonal Pattern, With Rapid
Cycling)
The following examples illustrate how to record

a Mood Disorder diagnosis with
specifiers:
· 296.32 Major Depressive Disorder,

Recurrent, Moderate, With Atypical
Features, With Seasonal Pattern, With Full
Interepisode Recovery
· 296.54 Bipolar I Disorder, Most Recent
Episode Depressed, Severe With
Psychotic Features, With Melancholic Features,
With Rapid Cycling
Mood Episodes
Major Depressive Episode
Episode Features
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 activities. In children and adolescents, the
mood may be irritable rather than sad. The
individual must also experience at least four
additional symptoms drawn from a list that
includes changes in appetite or weight, sleep,
and psychomotor activity; decreased
energy; feelings of worthlessness or guilt;
difficulty thinking, concentrating, or making
decisions; or recurrent thoughts of death or
suicidal ideation, plans, or attempts. To
count toward a Major Depressive Episode, a
symptom must either be newly present or
must have clearly worsened compared with the
person's preepisode status. The
symptoms must persist for most of the day,
nearly every day, for at least 2 consecutive
weeks. The episode must be accompanied by
clinically significant distress or impairment
in social, occupational, or other important areas
of functioning. For some individuals with
milder episodes, functioning may appear to be
normal but requires markedly increased
effort.
The mood in a Major Depressive Episode is

often described by the person as
depressed, sad, hopeless, discouraged, or "down
in the dumps" (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 about 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 person's facial expression and
demeanor. Some individuals emphasize somatic
complaints (e.g., bodily aches and
pains) rather than reporting feelings of sadness.
Many individuals report or exhibit
increased irritability (e.g., persistent anger, a
tendency to respond to events with angry
outbursts or blaming others, or an exaggerated
sense of frustration over minor matters).
In children and adolescents, an irritable or
cranky mood may develop rather than a sad
or dejected mood. This presentation should be
differentiated from a "spoiled child"
pattern of irritability when frustrated.
Loss of interest or pleasure is nearly always

present, at least to some degree.
Individuals may report feeling less interested in
hobbies, "not caring anymore," or not
feeling any enjoyment in activities that were
previously considered pleasurable (Criterion
A2). Family members often notice social
withdrawal or neglect of pleasurable avocations
(e.g., a formerly 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 sexual interest or desire.
Appetite is usually reduced, and many
individuals feel that they have to force
themselves to eat. Other individuals, particularly
those encountered in ambulatory
settings, may have increased appetite 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).
The most common sleep disturbance associated

with a Major Depressive Episode is
insomnia (Criterion A4). Individuals typically
have middle insomnia (i.e., waking up
during the night and having difficulty returning
to sleep) or terminal insomnia (i.e., waking
too early and being unable to return to sleep).
Initial insomnia (i.e., difficulty falling
asleep) may also occur. Less frequently,
individuals present with oversleeping
(hypersomnia) in the form of prolonged sleep
episodes at night or increased daytime
sleep. Sometimes the reason that the individual
seeks treatment is for the disturbed
sleep.
Psychomotor changes include agitation (e.g., the

inability to sit still, pacing, hand-
wringing; or pulling or rubbing of the skin,
clothing, or other objects) or retardation (e.g.,
slowed speech, thinking, and body movements;
increased pauses before answering;
speech that is decreased in volume, inflection,
amount, or variety of content, or
muteness) (Criterion A5). The psychomotor
agitation or retardation must be severe
enough to be observable by others and not
represent merely subjective feelings.
Decreased energy, tiredness, and fatigue are

common (Criterion A6). A person may
report sustained fatigue without physical
exertion. Even the smallest tasks seem to
require substantial effort. The efficiency with
which tasks are accomplished may be
reduced. For example, an individual may
complain that washing and dressing in the
morning are exhausting and take twice as long
as usual.
The sense of worthlessness or guilt associated

with a Major Depressive Episode may
include unrealistic negative evaluations of one's
worth or guilty preoccupations or
ruminations over minor past failings (Criterion
A7). Such individuals often misinterpret
neutral or trivial day-to-day events as evidence
of personal defects and have an
exaggerated sense of responsibility for untoward
events. For example, a realtor may
become preoccupied with self-blame for failing
to make sales even when the market has
collapsed generally and other realtors are
equally unable to make sales. The sense of
worthlessness or guilt may be of delusional
proportions (e.g., an individual who is
convinced that he or she is personally
responsible 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 considered sufficient to
meet this criterion.
Many individuals report impaired ability to

think, concentrate, or make decisions
(Criterion A8). They may appear easily
distracted or complain of memory difficulties.
Those in intellectually demanding academic or
occupational pursuits are often unable to
function adequately even when they have mild
concentration problems (e.g., a computer
programmer who can no longer perform
complicated but previously manageable tasks).
In children, a precipitous drop in grades may
reflect poor concentration. In elderly
individuals with a Major Depressive Episode,
memory difficulties may be the chief
complaint and may be mistaken for early signs
of a dementia ("pseudodementia"). When
the Major Depressive Episode is successfully
treated, the memory problems often fully
abate. However, in some individuals,
particularly elderly persons, a Major Depressive
Episode may sometimes be the initial
presentation of an irreversible dementia.
Frequently there may be thoughts of death,

suicidal ideation, or suicide attempts
(Criterion A9). These thoughts range from a
belief that others would be better off if the
person were dead, to transient but recurrent
thoughts of committing suicide, to actual
specific plans of how to commit suicide. The
frequency, intensity, and lethality of these
thoughts can be quite variable. Less severely
suicidal individuals may report transient (1-
to 2-minute), recurrent (once or twice a week)
thoughts. More severely suicidal
individuals may have acquired materials (e.g., a
rope or a gun) to be used in the suicide
attempt and may have established a location and
time when they will be isolated from
others so that they can accomplish the suicide.

Although these behaviors are associated
statistically with suicide attempts and may be
helpful in identifying a high-risk group,
many studies have shown that it is not possible
to predict accurately whether or when a
particular individual with depression will
attempt suicide. Motivations for suicide may
include a desire to give up in the face of
perceived insurmountable obstacles or an
intense wish to end an excruciatingly painful
emotional state that is perceived by the
person to be without end.
A diagnosis of a Major Depressive Episode is

not made if the symptoms meet criteria
for a Mixed Episode (Criterion B). A Mixed
Episode is characterized by the symptoms of
both a Manic Episode and a Major Depressive
Episode occurring nearly every day for at
least a 1-week period.
The degree of impairment associated with a

Major Depressive Episode varies, but
even in mild cases, there must be either
clinically significant distress or some
interference in social, occupational, or other
important areas of functioning (Criterion C).
If impairment is severe, the person may lose the
ability to function socially or
occupationally. In extreme cases, the person
may be unable to perform minimal self-care
(e.g., feeding or clothing self) or to maintain
minimal personal hygiene.
A careful interview is essential to elicit

symptoms of a Major Depressive Episode.
Reporting may be compromised by difficulties
in concentrating, impaired memory, or a
tendency to deny, discount, or explain away
symptoms. Information from additional
informants can be especially helpful in
clarifying the course of current or prior Major
Depressive Episodes and in assessing whether
there have been any Manic or
Hypomanic Episodes. Because Major
Depressive Episodes can begin gradually, a
review of clinical information that focuses on
the worst part of the current episode may
be most likely to detect the presence of
symptoms. The evaluation of the symptoms of a
Major Depressive Episode is especially difficult
when they occur in an individual who
also has a general medical condition (e.g.,
cancer, stroke, myocardial infarction,
diabetes). Some of the criterion items of a Major
Depressive Episode are identical to the
characteristic signs and symptoms of general
medical conditions (e.g., weight loss with
untreated diabetes, fatigue with cancer). Such
symptoms should count toward a Major
Depressive Episode except when they are clearly
and fully accounted for by a general
medical condition. For example, weight loss in a
person with ulcerative colitis who has
many bowel movements and little food intake
should not be counted toward a Major
Depressive Episode. On the other hand, when
sadness, guilt, insomnia, or weight loss
are present in a person with a recent myocardial
infarction, each symptom would count
toward a Major Depressive Episode because
these are not clearly and fully accounted
for by the physiological effects of a myocardial
infarction. Similarly, when symptoms are
clearly due to mood-incongruent delusions or
hallucinations (e.g., a 30-pound weight
loss related to not eating because of a delusion
that one's food is being poisoned), these
symptoms do not count toward a Major
Depressive Episode.
By definition, a Major Depressive Episode is not

due to the direct physiological effects
of a drug of abuse (e.g., in the context of
Alcohol Intoxication or Cocaine Withdrawal), to
the side effects of medications or treatments
(e.g., steroids), or to toxin exposure.
Similarly, the episode is not due to the direct
physiological effects of a general medical
condition (e.g., hypothyroidism) (Criterion D).
Moreover, if the symptoms begin within 2
months of the loss of a loved one and do not
persist beyond these 2 months, they are
generally considered to result from Bereavement
(See linked section), unless they are
associated with marked functional impairment or
include morbid preoccupation with
worthlessness, suicidal ideation, psychotic
symptoms, or psychomotor retardation
(Criterion E).
Associated Features and Disorders
Associated descriptive features and mental

disorders. Individuals with a Major
Depressive Episode frequently present with
tearfulness, irritability, brooding, obsessive
rumination, anxiety, phobias, excessive worry
over physical health, and complaints of
pain (e.g., headaches or joint, abdominal, or
other pains). During a Major Depressive
Episode, some individuals have Panic Attacks
that occur in a pattern that meets criteria
for Panic Disorder. In children, separation
anxiety may occur. Some individuals note
difficulty in intimate relationships, less
satisfying social interactions, or difficulties in
sexual functioning (e.g., anorgasmia in women
or erectile dysfunction in men). There
may be marital problems (e.g., divorce),
occupational problems (e.g., loss of job),
academic problems (e.g., truancy, school
failure), Alcohol or Other Substance Abuse, or
increased utilization of medical services. The
most serious consequence of a Major
Depressive Episode is attempted or completed
suicide. Suicide risk is especially high for
individuals with psychotic features, a history of
previous suicide attempts, a family history
of completed suicides, or concurrent substance
use. There may also be an increased
rate of premature death from general medical
conditions. Major Depressive Episodes
often follow psychosocial stressors (e.g., the
death of a loved one, marital separation,
divorce). Childbirth may precipitate a Major
Depressive Episode, in which case the
specifier With Postpartum Onset is noted (See
linked section).
Associated laboratory findings. No laboratory
findings that are diagnostic of a Major
Depressive Episode have been identified.
However, a variety of laboratory findings have
been noted to be abnormal more often in groups
of individuals with Major Depressive
Episodes compared with control subjects. It
appears that the same laboratory
abnormalities are associated with a Major
Depressive Episode regardless of whether the
episode is part of a Major Depressive, Bipolar I,
or Bipolar II Disorder. Most laboratory
abnormalities are state dependent (i.e., affected
by the presence or absence of
depressive symptoms), but some findings may
precede the onset of the episode or
persist after its remission. Laboratory tests are
more likely to be abnormal in episodes
with melancholic or psychotic features and in
more severely depressed individuals.
Sleep EEG abnormalities may be evident in

40%60% of outpatients and in up to
90% of inpatients with a Major Depressive
Episode. The most frequently associated
polysomnographic findings include 1) sleep
continuity disturbances, such as prolonged
sleep latency, increased intermittent
wakefulness, and early morning awakening; 2)
reduced non-rapid eye movement (NREM)
stages 3 and 4 sleep (slow-wave sleep), with
a shift in slow-wave activity away from the first
NREM period; 3) decreased rapid eye
movement (REM) latency (i.e., shortened
duration of the first NREM period); 4)
increased phasic REM activity (i.e., the number
of actual eye movements during REM);
and 5) increased duration of REM sleep early in
the night. There is evidence that these
sleep abnormalities may persist after clinical
remission or precede the onset of the initial
Major Depressive Episode among those at high
risk for a Mood Disorder (e.g., first-
degree family members of individuals with
Major Depressive Disorder).
The pathophysiology of a Major Depressive

Episode may involve a dysregulation of a
number of neurotransmitter systems, including
the serotonin, norepinephrine, dopamine,
acetylcholine, and gamma-aminobutyric acid
systems. There is also evidence of
alterations of several neuropeptides, including
corticotropin-releasing hormone. In some
depressed individuals, hormonal disturbances
have been observed, including elevated
glucocorticoid secretion (e.g., elevated urinary
free cortisol levels or dexamethasone
nonsuppression of plasma cortisol) and blunted
growth hormone, thyroid-stimulating
hormone, and prolactin responses to various
challenge tests. Functional brain imaging
studies document alterations in cerebral blood
flow and metabolism in some individuals,
including increased blood flow in limbic and
paralimbic regions and decreased blood flow
in the lateral prefrontal cortex. Depression
beginning in late life is associated with
alterations in brain structure, including
periventricular vascular changes. None of these
changes are present in all individuals in a Major
Depressive Episode, however, nor is
any particular disturbance specific to depression.
Specific Culture, Age, and Gender Features
Culture can influence the experience and

communication of symptoms of depression.
Underdiagnosis or misdiagnosis can be reduced
by being alert to ethnic and cultural
specificity in the presenting complaints of a
Major Depressive Episode. For example, in
some cultures, depression may be experienced
largely in somatic terms, rather than with
sadness or guilt. Complaints of "nerves" and
headaches (in Latino and Mediterranean
cultures), of weakness, tiredness, or "imbalance"
(in Chinese and Asian cultures), of
problems of the "heart" (in Middle Eastern
cultures), or of being "heartbroken" (among
Hopi) may express the depressive experience.
Such presentations combine features of
the Depressive, Anxiety, and Somatoform
Disorders. Cultures also may differ in
judgments about the seriousness of experiencing
or expressing dysphoria (e.g.,
irritability may provoke greater concern than
sadness or withdrawal). Culturally
distinctive experiences (e.g., fear of being hexed
or bewitched, feelings of "heat in the
head" or crawling sensations of worms or ants,
or vivid feelings of being visited by those
who have died) must be distinguished from
actual hallucinations or delusions that may
be part of a Major Depressive Episode, With
Psychotic Features. It is also imperative
that the clinician not routinely dismiss a
symptom merely because it is viewed as the
"norm" for a culture.
The core symptoms of a Major Depressive

Episode are the same for children and
adolescents, although there are data that suggest
that the prominence of characteristic
symptoms may change with age. Certain
symptoms such as somatic complaints,
irritability, and social withdrawal are
particularly common in children, whereas
psychomotor retardation, hypersomnia, and
delusions are less common in prepuberty
than in adolescence and adulthood. In
prepubertal children, Major Depressive Episodes
occur more frequently in conjunction with other
mental disorders (especially Disruptive
Behavior Disorders, Attention-Deficit Disorders,
and Anxiety Disorders) than in isolation.
In adolescents, Major Depressive Episodes are
frequently associated with Disruptive
Behavior Disorders, Attention-Deficit Disorders,
Anxiety Disorders, Substance-Related
Disorders, and Eating Disorders. In elderly
adults, cognitive symptoms (e.g.,
disorientation, memory loss, and distractibility)
may be particularly prominent.
Women are at significantly greater risk than men

to develop Major Depressive
Episodes at some point during their lives, with
the greatest differences found in studies
conducted in the United States and Europe. This
increased differential risk emerges
during adolescence and may coincide with the
onset of puberty. Thereafter, a significant
proportion of women report a worsening of the
symptoms of a Major Depressive Episode
several days before the onset of menses. Studies
indicate that depressive episodes
occur twice as frequently in women as in men.
See the corresponding sections of the
texts for Major Depressive Disorder (See linked
section), Bipolar I Disorder (See linked
section), and Bipolar II Disorder (See linked
section) for specific information on gender.
Course
Symptoms of a Major Depressive Episode

usually develop over days to weeks. A
prodromal period that may include anxiety
symptoms and mild depressive symptoms
may last for weeks to months before the onset of
a full Major Depressive Episode. The
duration of a Major Depressive Episode is also
variable. An untreated episode typically
lasts 4 months or longer, regardless of age at
onset. In a majority of cases, there is
complete remission of symptoms, and
functioning returns to the premorbid level. In a
significant proportion of cases (perhaps
20%30%), some depressive symptoms
insufficient to meet full criteria for a Major
Depressive Episode may persist for months to
years and may be associated with some
disability or distress (in which case the specifier
In Partial Remission may be noted; See linked
section). Partial remission following a
Major Depressive Episode appears to be
predictive of a similar pattern after subsequent
episodes. In some individuals (5%10%), the
full criteria for a Major Depressive Episode
continue to be met for 2 or more years (in which
case the specifier Chronic may be
noted; See linked section).
Differential Diagnosis
A Major Depressive Episode must be

distinguished from a Mood Disorder Due to a
General Medical Condition. The appropriate
diagnosis would be Mood Disorder Due to
a General Medical Condition if the mood
disturbance is judged to be the direct
physiological consequence of a specific general
medical condition (e.g., multiple
sclerosis, stroke, hypothyroidism) (See linked
section). This determination is based on
the history, laboratory findings, or physical
examination. If both a Major Depressive
Episode and a general medical condition are
present but it is judged that the depressive
symptoms are not the direct physiological
consequence of the general medical condition,
then the primary Mood Disorder is recorded on
Axis I (e.g., Major Depressive Disorder)
and the general medical condition is recorded on
Axis III (e.g., myocardial infarction).
This would be the case, for example, if the
Major Depressive Episode is considered to
be the psychological consequence of having the
general medical condition or if there is
no etiological relationship between the Major
Depressive Episode and the general
medical condition.
A Substance-Induced Mood Disorder is

distinguished from a Major Depressive
Episode by the fact that a substance (e.g., a drug
of abuse, a medication, or a toxin) is
judged to be etiologically related to the mood
disturbance (See linked section). For
example, depressed mood that occurs only in the
context of withdrawal from cocaine
would be diagnosed as Cocaine-Induced Mood
Disorder, With Depressive Features,
With Onset During Withdrawal.
In elderly persons, it is often difficult to

determine whether cognitive symptoms (e.g.,
disorientation, apathy, difficulty concentrating,
memory loss) are better accounted for by
a dementia or by a Major Depressive Episode. A
thorough medical evaluation and an
evaluation of the onset of the disturbance,
temporal sequencing of depressive and
cognitive symptoms, course of illness, and
treatment response are helpful in making this
determination. The premorbid state of the
individual may help to differentiate a Major
Depressive Episode from a dementia. In a
dementia, there is usually a premorbid history
of declining cognitive function, whereas the
individual with a Major Depressive Episode
is much more likely to have a relatively normal
premorbid state and abrupt cognitive
decline associated with the depression.
Major Depressive Episodes with prominent

irritable mood may be difficult to
distinguish from Manic Episodes with irritable
mood or from Mixed Episodes. This
distinction requires a careful clinical evaluation
of the presence of manic symptoms. If
criteria are met for both a Manic Episode and a
Major Depressive Episode (except for
the 2-week duration) nearly every day for at
least a 1-week period, this would constitute
a Mixed Episode.
Distractibility and low frustration tolerance can

occur in both Attention-Deficit/
Hyperactivity Disorder and a Major Depressive
Episode; if the criteria are met for both,
Attention-Deficit/Hyperactivity Disorder may be
diagnosed in addition to the Mood
Disorder. However, the clinician must be
cautious not to overdiagnose a Major
Depressive Episode in children with Attention-
Deficit/Hyperactivity Disorder whose
disturbance in mood is characterized by
irritability rather than by sadness or loss of
interest.
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. After the loss
of a loved one, even if depressive symptoms are
of sufficient duration and number to
meet criteria for a Major Depressive Episode,
they should be attributed to Bereavement
rather than to a Major Depressive Episode,
unless they persist for more than 2 months or
include marked functional impairment, morbid

preoccupation with worthlessness, suicidal
ideation, psychotic symptoms, or psychomotor
retardation.
Finally, periods of sadness are inherent aspects

of the human experience. These
periods should not be diagnosed as a Major
Depressive Episode unless criteria are met
for severity (i.e., five out of nine symptoms),
duration (i.e., most of the day, nearly every
day for at least 2 weeks), and clinically
significant distress or impairment. The diagnosis
Depressive Disorder Not Otherwise Specified
may be appropriate for presentations of
depressed mood with clinically significant
impairment that do not meet criteria for
duration or severity.
Criteria for Major Depressive Episode
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
due to a general medical
condition, or mood-incongruent delusions or
hallucinations.
1. depressed mood most of the day, nearly every
day, as indicated by
either subjective report (e.g., feels sad or empty)
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 made by others)
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
decrease or increase in
appetite nearly every day. Note: In children,
consider failure to make
expected weight gains.
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 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 (either by subjective account or as observed
by others)
9. recurrent thoughts of death (not just fear of
dying), recurrent suicidal
ideation without a specific plan, or a suicide
attempt or a specific plan for
committing suicide
B. The symptoms do not meet criteria for a
Mixed Episode (See linked section).
C. The symptoms cause clinically significant
distress or impairment in social,
occupational, or other important areas of
functioning.
D. The symptoms are not due to the direct
physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general
medical condition (e.g.,
hypothyroidism).
E. The symptoms are not better accounted for by
Bereavement, i.e., after the
loss of a loved one, the symptoms persist for
longer than 2 months or are
characterized by marked functional impairment,
morbid preoccupation with
worthlessness, suicidal ideation, psychotic
symptoms, or psychomotor
retardation.
Manic Episode
Episode Features
A Manic Episode is defined by a distinct period

during which there is an abnormally and
persistently elevated, expansive, or irritable
mood. This period of abnormal mood must
last at least 1 week (or less if hospitalization is
required) (Criterion A). The mood
disturbance must be accompanied by at least
three additional symptoms from a list that
includes inflated self-esteem or grandiosity,
decreased need for sleep, pressure of
speech, flight of ideas, distractibility, increased
involvement in goal-directed activities or
psychomotor agitation, and excessive
involvement in pleasurable activities with a high
potential for painful consequences. If the mood
is irritable (rather than elevated or
expansive), at least four of the above symptoms
must be present (Criterion B). The
symptoms do not meet criteria for a Mixed
Episode, which is characterized by the
symptoms of both a Manic Episode and a Major
Depressive Episode occurring nearly
every day for at least a 1-week period (Criterion
C). The disturbance must be sufficiently
severe to cause marked impairment in social or
occupational functioning or to require
hospitalization, or it is characterized by the
presence of psychotic features (Criterion D).
The episode must not be due to the direct
physiological effects of a drug of abuse, a
medication, other somatic treatments for
depression (e.g., electroconvulsive therapy or
light therapy), or toxin exposure. The episode
must also not be due to the direct
condition (e.g., multiple sclerosis, brain tumor)
(Criterion E).
The elevated mood of a Manic Episode may be

described as euphoric, unusually
good, cheerful, or high. Although the person's
mood may initially have an infectious
quality for the uninvolved observer, it is
recognized as excessive by those who know the
person well. The expansive quality of the mood
is characterized by unceasing and
indiscriminate enthusiasm for interpersonal,
sexual, or occupational interactions. For
example, the person may spontaneously start
extensive conversations with strangers in
public places, or a salesperson may telephone
strangers at home in the early morning
hours to initiate sales. Although elevated mood
is considered the prototypical symptom,
the predominant mood disturbance may be
irritability, particularly when the person's
wishes are thwarted. Lability of mood (e.g., the

alternation between euphoria and
irritability) is frequently seen.
Inflated self-esteem is typically present, ranging

from uncritical self-confidence to
marked grandiosity, and may reach delusional
proportions (Criterion B1). Individuals
may give advice on matters about which they
have no special knowledge (e.g., how to
run the United Nations). Despite lack of any
particular experience or talent, the individual
may embark on writing a novel or composing a
symphony or seek publicity for some
impractical invention. Grandiose delusions are
common (e.g., having a special
relationship to God or to some public figure
from the political, religious, or entertainment
world).
Almost invariably, there is a decreased need for

sleep (Criterion B2). The person
usually awakens several hours earlier than usual,
feeling full of energy. When the sleep
disturbance is severe, the person may go for
days without sleep and yet not feel tired.
Manic speech is typically pressured, loud, rapid,

and difficult to interrupt (Criterion
B3). Individuals may talk nonstop, sometimes
for hours on end, and without regard for
others' wishes to communicate. Speech is
sometimes characterized by joking, punning,
and amusing irrelevancies. The individual may
become theatrical, with dramatic
mannerisms and singing. Sounds rather than
meaningful conceptual relationships may
govern word choice (i.e., clanging). If the
person's mood is more irritable than expansive,
speech may be marked by complaints, hostile
comments, or angry tirades.
The individual's thoughts may race, often at a

rate faster than can be articulated
(Criterion B4). Some individuals with Manic
Episodes report that this experience
resembles watching two or three television
programs simultaneously. Frequently there is
flight of ideas evidenced by a nearly continuous
flow of accelerated speech, with abrupt
changes from one topic to another. For example,
while talking about a potential business
deal to sell computers, a salesperson may shift to
discussing in minute detail the history
of the computer chip, the industrial revolution,
or applied mathematics. When flight of
ideas is severe, speech may become
disorganized and incoherent.
Distractibility (Criterion B5) is evidenced by an

inability to screen out irrelevant
external stimuli (e.g., the interviewer's tie,
background noises or conversations, or
furnishings in the room). There may be a
reduced ability to differentiate between
thoughts that are germane to the topic and
thoughts that are only slightly relevant or
clearly irrelevant.
The increase in goal-directed activity often

involves excessive planning of, and
excessive participation in, multiple activities

(e.g., sexual, occupational, political,
religious) (Criterion B6). Increased sexual drive,
fantasies, and behavior are often
present. The person may simultaneously take on
multiple new business ventures without
regard for the apparent risks or the need to
complete each venture satisfactorily. Almost
invariably, there is increased sociability (e.g.,
renewing old acquaintances or calling
friends or even strangers at all hours of the day
or night), without regard to the intrusive,
domineering, and demanding nature of these
interactions. Individuals often display
psychomotor agitation or restlessness by pacing
or by holding multiple conversations
simultaneously (e.g., by telephone and in person
at the same time). Some individuals
write a torrent of letters on many different topics
to friends, public figures, or the media.
Expansiveness, unwarranted optimism,

grandiosity, and poor judgment often lead to
an imprudent involvement in pleasurable
activities such as buying sprees, reckless
driving, foolish business investments, and sexual
behavior unusual for the person, even
though these activities are likely to have painful
consequences (Criterion B7). The
individual may purchase many unneeded items
(e.g., 20 pairs of shoes, expensive
antiques) without the money to pay for them.
Unusual sexual behavior may include
infidelity or indiscriminate sexual encounters
with strangers.
The impairment resulting from the disturbance

must be severe enough to cause
marked impairment in functioning or to require
hospitalization to protect the individual
from the negative consequences of actions that
result from poor judgment (e.g., financial
losses, illegal activities, loss of employment,
assaultive behavior). By definition, the
presence of psychotic features during a Manic
Episode constitutes marked impairment in
functioning (Criterion D).
Symptoms like those seen in a Manic Episode

may be due to the direct effects of
antidepressant medication, electroconvulsive
therapy, light therapy, or medication
prescribed for other general medical conditions
(e.g., corticosteroids). Such
presentations are not considered Manic Episodes
and do not count toward the diagnosis
of Bipolar I Disorder. For example, if a person
with recurrent Major Depressive Disorder
develops manic symptoms following a course of
antidepressant medication, the episode
is diagnosed as a Substance-Induced Mood
Disorder, With Manic Features, and there is
no switch from a diagnosis of Major Depressive
Disorder to Bipolar I Disorder. Some
evidence suggests that there may be a bipolar
"diathesis" in individuals who develop
manic-like episodes following somatic treatment
for depression. Such individuals may
have an increased likelihood of future Manic,
Mixed, or Hypomanic Episodes that are not
related to substances or somatic treatments for
depression. This may be an especially
important consideration in children and
adolescents.

disorders. Individuals with a Manic
Episode frequently do not recognize that they
are ill and resist efforts to be treated. They
may travel impulsively to other cities, losing
contact with relatives and caretakers. They
may change their dress, makeup, or personal
appearance to a more sexually suggestive
or dramatically flamboyant style that is out of
character for them. They may engage in
activities that have a disorganized or bizarre
quality (e.g., distributing candy, money, or
advice to passing strangers). Gambling and
antisocial behaviors may accompany the
Manic Episode. Ethical concerns may be
disregarded even by those who are typically
very conscientious (e.g., a stockbroker
inappropriately buys and sells stock without the
clients' knowledge or permission; a scientist
incorporates the findings of others). The
person may be hostile and physically threatening
to others. Some individuals, especially
those with psychotic features, may become
physically assaultive or suicidal. Adverse
consequences of a Manic Episode (e.g.,
involuntary hospitalization, difficulties with the
law, or serious financial difficulties) often result
from poor judgment and hyperactivity.
When no longer in the Manic Episode, most
individuals are regretful for behaviors
engaged in during the Manic Episode. Some
individuals describe having a much sharper
sense of smell, hearing, or vision (e.g., colors
appear very bright). When catatonic
symptoms (e.g., stupor, mutism, negativism, and
posturing) are present, the specifier
With Catatonic Features may be indicated (See
linked section).
Mood may shift rapidly to anger or depression.

Depressive symptoms may last
moments, hours, or, more rarely, days. Not
uncommonly, the depressive symptoms and
manic symptoms occur simultaneously. If the
criteria for both a Major Depressive
Episode and a Manic Episode are prominent
every day for at least 1 week, the episode
is considered to be a Mixed Episode (See linked
section). As the Manic Episode
develops, there is often a substantial increase in
the use of alcohol or stimulants, which
may exacerbate or prolong the episode.
Associated laboratory findings. No laboratory
findings that are diagnostic of a Manic
Episode have been identified. However, a
variety of laboratory findings have been noted
to be abnormal in groups of individuals with
Manic Episodes compared with control
subjects. Laboratory findings in Manic Episodes
include polysomnographic abnormalities
and increased cortisol secretion. There may be
abnormalities involving the
norepinephrine, serotonin, acetylcholine,
dopamine, or gamma-aminobutyric acid
neurotransmitter systems, as demonstrated by
studies of neurotransmitter metabolites,
receptor functioning, pharmacological

provocation, and neuroendocrine function.

Cultural considerations that were suggested for
Major Depressive Episodes are also
relevant to Manic Episodes (See linked section).
Manic Episodes in adolescents are
more likely to include psychotic features and
may be associated with school truancy,
antisocial behavior, school failure, or substance
use. A significant minority of
adolescents appear to have a history of long-
standing behavior problems that precede
the onset of a frank Manic Episode. It is unclear
whether these problems represent a
prolonged prodrome to Bipolar Disorder or an
independent disorder. See the
corresponding sections of the texts for Bipolar I
Disorder (See linked section) and Bipolar
II Disorder (See linked section) for specific
information on gender.
Course
The mean age at onset for a first Manic Episode
is the early 20s, but some cases start in
adolescence and others start after age 50 years.
Manic Episodes typically begin
suddenly, with a rapid escalation of symptoms
over a few days. Frequently, Manic
Episodes occur following psychosocial stressors.
The episodes usually last from a few
weeks to several months and are briefer and end
more abruptly than Major Depressive
Episodes. In many instances (50%60%), a
Major Depressive Episode immediately
precedes or immediately follows a Manic
Episode, with no intervening period of
euthymia. If the Manic Episode occurs in the
postpartum period, there may be an
increased risk for recurrence in subsequent
postpartum periods and the specifier With
Postpartum Onset is applicable (See linked
section).
A Manic Episode must be distinguished from a
Mood Disorder Due to a General
Medical Condition. The appropriate diagnosis
would be Mood Disorder Due to a
General Medical Condition if the mood
disturbance is judged to be the direct
physiological consequence of a specific general
medical condition (e.g., multiple
sclerosis, brain tumor, Cushing's syndrome) (See
linked section). This determination is
based on the history, laboratory findings, or
physical examination. If it is judged that the
manic symptoms are not the direct physiological

consequence of the general medical
condition, then the primary Mood Disorder is
recorded on Axis I (e.g., Bipolar I Disorder)
Axis III (e.g., myocardial infarction). A
late onset of a first Manic Episode (e.g., after
age 50 years) should alert the clinician to
the possibility of an etiological general medical
condition or substance.

distinguished from a Manic Episode by the
fact that a substance (e.g., a drug of abuse, a
medication, or exposure to a toxin) is
disturbance (See linked section).
Symptoms like those seen in a Manic Episode
may be precipitated by a drug of abuse
(e.g., manic symptoms that occur only in the
context of intoxication with cocaine would
be diagnosed as Cocaine-Induced Mood
Disorder, With Manic Features, With Onset
During Intoxication). Symptoms like those seen
in a Manic Episode may also be
precipitated by antidepressant treatment such as
medication, electroconvulsive therapy,
or light therapy. Such episodes are also
diagnosed as Substance-Induced Mood
Disorders (e.g., Amitriptyline-Induced Mood
Disorder, With Manic Features;
Electroconvulsive Therapy-Induced Mood
Disorder, With Manic Features). However,
clinical judgment is essential to determine
whether the treatment is truly causal or
whether a primary Manic Episode happened to
have its onset while the person was
receiving the treatment (See linked section).
Manic Episodes should be distinguished from

Hypomanic Episodes. Although Manic
Episodes and Hypomanic Episodes have an
identical list of characteristic symptoms, the
disturbance in Hypomanic Episodes is not
sufficiently severe to cause marked
impairment in social or occupational functioning
or to require hospitalization. Some
Hypomanic Episodes may evolve into full
Manic Episodes.
irritable mood may be difficult to
distinguish from Manic Episodes with irritable
mood or from Mixed Episodes. This
determination requires a careful clinical
evaluation of the presence of manic symptoms.
If criteria are met for both a Manic Episode and
a Major Depressive Episode nearly every
day for at least a 1-week period, this would
constitute a Mixed Episode.
Attention-Deficit/Hyperactivity Disorder and a

Manic Episode are both
characterized by excessive activity, impulsive
behavior, poor judgment, and denial of
problems. Attention-Deficit/Hyperactivity
Disorder is distinguished from a Manic Episode
by its characteristic early onset (i.e., before age 7
years), chronic rather than episodic
course, lack of relatively clear onsets and
offsets, and the absence of abnormally
expansive or elevated mood or psychotic
features.
Criteria for Manic Episode
A. A distinct period of abnormally and

persistently elevated, expansive, or
irritable mood, lasting at least 1 week (or any
duration if hospitalization is
necessary).
B. During the period of mood disturbance, three
(or more) of the following
symptoms have persisted (four if the mood is
only irritable) and have been
present to a significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep (e.g., feels rested
after only 3 hours of sleep)
3. more talkative than usual or pressure to keep
talking
4. flight of ideas or subjective experience that
thoughts are racing
5. distractibility (i.e., attention too easily drawn
to unimportant or irrelevant
external stimuli)
6. increase in goal-directed activity (either
socially, at work or school, or
sexually) or psychomotor agitation
7. excessive involvement in pleasurable
activities that have a high potential
for painful consequences (e.g., engaging in
unrestrained buying sprees,
sexual indiscretions, or foolish business
investments)
C. The symptoms do not meet criteria for a
D. The mood disturbance is sufficiently severe
to cause marked impairment in
occupational functioning or in usual social
activities or relationships with others,
or to necessitate hospitalization to prevent harm
to self or others, or there are
psychotic features.
E. The symptoms are not due to the direct
(e.g., a drug of abuse, a medication, or other
treatment) or a general medical
condition (e.g., hyperthyroidism).
Note: Manic-like episodes that are clearly
caused by somatic antidepressant
treatment (e.g., medication, electroconvulsive
therapy, light therapy) should not
count toward a diagnosis of Bipolar I Disorder.
Mixed Episode
Episode Features
A Mixed Episode is characterized by a period of
time (lasting at least 1 week) in which
the criteria are met both for a Manic Episode and
for a Major Depressive Episode nearly
every day (Criterion A). The individual
experiences rapidly alternating moods (sadness,
irritability, euphoria) accompanied by symptoms
of a Manic Episode (See linked section)
and a Major Depressive Episode (See linked
section). The symptom presentation
frequently includes agitation, insomnia, appetite
dysregulation, psychotic features, and
suicidal thinking. The disturbance must be
or to require hospitalization, or it is
characterized by the presence of psychotic
features (Criterion B). The disturbance is not
due to the direct physiological effects of a
substance (e.g., a drug of abuse, a
medication, or other treatment) or a general
medical condition (e.g., hyperthyroidism)
(Criterion C). Symptoms like those seen in a
Mixed Episode may be due to the direct
effects of antidepressant medication,
electroconvulsive therapy, light therapy, or
medication prescribed for other general medical
conditions (e.g., corticosteroids). Such
presentations are not considered Mixed Episodes
and do not count toward a diagnosis
of Bipolar I Disorder. For example, if a person
with recurrent Major Depressive Disorder
develops a mixed symptom picture during a
course of antidepressant medication, the
diagnosis of the episode is Substance-Induced
Mood Disorder, With Mixed Features,
and there is no switch from a diagnosis of Major
Depressive Disorder to Bipolar I
Disorder. Some evidence suggests that there
may be a bipolar "diathesis" in individuals
who develop mixed-like episodes following
somatic treatment for depression. Such
individuals may have an increased likelihood of
future Manic, Mixed, or Hypomanic
Episodes that are not related to substances or
somatic treatments for depression. This
may be an especially important consideration in
children and adolescents.

disorders. Associated features of a
Mixed Episode are similar to those for Manic
Episodes and Major Depressive Episodes.
Individuals may be disorganized in their
thinking or behavior. Because individuals in
Mixed Episodes experience more dysphoria than
do those in Manic Episodes, they may
be more likely to seek help.
Associated laboratory findings. Laboratory
findings for Mixed Episode are not well
studied, although evidence to date suggests
physiological and endocrine findings that
are similar to those found in severe Major
Depressive Episodes.
Cultural considerations suggested for Major

Depressive Episodes are relevant to Mixed
Episodes as well (See linked section). Mixed
episodes appear to be more common in
younger individuals and in individuals over age
60 years with Bipolar Disorder and may
be more common in males than in females.
Course
Mixed Episodes can evolve from a Manic

Episode or from a Major Depressive Episode
or may arise de novo. For example, the
diagnosis would be changed from Bipolar I
Disorder, Most Recent Episode Manic, to
Bipolar I Disorder, Most Recent Episode
Mixed, for an individual with 3 weeks of manic
symptoms followed by 1 week of both
manic symptoms and depressive symptoms.
Mixed episodes may last weeks to several
months and may remit to a period with few or no
symptoms or evolve into a Major
Depressive Episode. It is far less common for a
Mixed Episode to evolve into a Manic
Episode.
A Mixed Episode must be distinguished from a

Mood Disorder Due to a General
Medical Condition. The diagnosis is Mood
Disorder Due to a General Medical Condition
if the mood disturbance is judged to be the direct
physiological consequence of a
specific general medical condition (e.g., multiple
sclerosis, brain tumor, Cushing's
syndrome) (See linked section). This
determination is based on the history, laboratory
findings, or physical examination. If it is judged
that the mixed manic and depressive
Axis I (e.g., Bipolar I Disorder) and the
general medical condition is recorded on Axis
III (e.g., myocardial infarction).

distinguished from a Mixed Episode by the
Symptoms like those seen in a Mixed Episode
may be precipitated by use of a drug of
abuse (e.g., mixed manic and depressive
symptoms that occur only in the context of
intoxication with cocaine would be diagnosed as
Cocaine-Induced Mood Disorder, With
Mixed Features, With Onset During
Intoxication). Symptoms like those seen in a
Mixed
Episode may also be precipitated by
antidepressant treatment such as medication,
electroconvulsive therapy, or light therapy. Such
episodes are also diagnosed as
Substance-Induced Mood Disorders (e.g.,
Amitriptyline-Induced Mood Disorder, With
Mixed Features; Electroconvulsive Therapy-
Induced Mood Disorder, With Mixed
Features). However, clinical judgment is
essential to determine whether the treatment is
truly causal or whether a primary Mixed Episode
happened to have its onset while the
person was receiving the treatment (See linked
section).

irritable mood and Manic Episodes
with prominent irritable mood may be difficult
to distinguish from Mixed Episodes. This
determination requires a careful clinical
evaluation of the simultaneous presence of
symptoms that are characteristic of both a full
Manic Episode and a full Major
Depressive Episode (except for duration).

Mixed Episode are both
Disorder is distinguished from a Mixed Episode
by its characteristic early onset (i.e., before age 7
years), chronic rather than episodic
course, lack of relatively clear onsets and
offsets, and the absence of abnormally
expansive or elevated mood or psychotic
features. Children with Attention-
Deficit/Hyperactivity Disorder also sometimes
show depressive symptoms such as low
self-esteem and frustration tolerance. If criteria
are met for both, Attention-
Deficit/Hyperactivity Disorder may be
diagnosed in addition to the Mood Disorder.
Criteria for Mixed Episode
A. The criteria are met both for a Manic Episode

(See linked section) and for a
Major Depressive Episode (See linked section)
(except for duration) nearly
every day during at least a 1-week period.
B. The mood disturbance is sufficiently severe
to cause marked impairment in
occupational functioning or in usual social
activities or relationships with others,
or to necessitate hospitalization to prevent harm
to self or others, or there are
psychotic features.
C. The symptoms are not due to the direct
Note: Mixed-like episodes that are clearly
caused by somatic antidepressant
treatment (e.g., medication, electroconvulsive
therapy, light therapy) should not
count toward a diagnosis of Bipolar I Disorder.
Hypomanic Episode
Episode Features
A Hypomanic Episode is defined as a distinct
period during which there is an abnormally
and persistently elevated, expansive, or irritable
mood that lasts at least 4 days (Criterion
A). This period of abnormal mood must be
accompanied by at least three additional
symptoms from a list that includes inflated self-
esteem or grandiosity (nondelusional),
decreased need for sleep, pressure of speech,
flight of ideas, distractibility, increased
involvement in goal-directed activities or
psychomotor agitation, and excessive
involvement in pleasurable activities that have a
high potential for painful consequences
(Criterion B). If the mood is irritable rather than
elevated or expansive, at least four of the
above symptoms must be present. This list of
additional symptoms is identical to those
that define a Manic Episode (See linked section)
except that delusions or hallucinations
cannot be present. The mood during a
Hypomanic Episode must be clearly different
from
the individual's usual nondepressed mood, and
there must be a clear change in
functioning that is not characteristic of the
individual's usual functioning (Criterion C).
Because the changes in mood and functioning
must be observable by others (Criterion
D), the evaluation of this criterion will often
require interviewing other informants (e.g.,
family members). History from other informants
is particularly important in the evaluation
of adolescents. In contrast to a Manic Episode, a
Hypomanic Episode is not severe
enough to cause marked impairment in social or
occupational functioning or to require
hospitalization, and there are no psychotic
features (Criterion E). The change in
functioning for some individuals may take the
form of a marked increase in efficiency,
accomplishments, or creativity. However, for
others, hypomania can cause some social
or occupational impairment.
The mood disturbance and other symptoms must

not be due to the direct
physiological effects of a drug of abuse, a
medication, other treatment for depression
(electroconvulsive therapy or light therapy), or
toxin exposure. The episode must also not
be due to the direct physiological effects of a
general medical condition (e.g., multiple
sclerosis, brain tumor) (Criterion F). Symptoms
like those seen in a Hypomanic Episode
may be due to the direct effects of antidepressant
light therapy, or medication prescribed for other

general medical conditions (e.g.,
corticosteroids). Such presentations are not
considered Hypomanic Episodes and do not
count toward the diagnosis of Bipolar II
Disorder. For example, if a person with recurrent
Major Depressive Disorder develops symptoms
of a hypomanic-like episode during a
course of antidepressant medication, the episode
is diagnosed as a Substance-Induced
Mood Disorder, With Manic Features, and there
is no switch from a diagnosis of Major
Depressive Disorder to Bipolar II Disorder.
Some evidence suggests that there may be a
bipolar "diathesis" in individuals who develop
manic- or hypomanic-like episodes
following somatic treatment for depression.
Such individuals may have an increased
likelihood of future Manic or Hypomanic
Episodes that are not related to substances or
somatic treatments for depression.
The elevated mood in a Hypomanic Episode is

described as euphoric, unusually
good, cheerful, or high. Although the person's
mood may have an infectious quality for
the uninvolved observer, it is recognized as a
distinct change from the usual self by
those who know the person well. The expansive
quality of the mood disturbance is
characterized by enthusiasm for social,
interpersonal, or occupational interactions.
Although elevated mood is considered
prototypical, the mood disturbance may be
irritable or may alternate between euphoria and
irritability. Characteristically, inflated self-
esteem, usually at the level of uncritical self-
confidence rather than marked grandiosity,
is present (Criterion B1). There is very often a
decreased need for sleep (Criterion B2);
the person awakens before the usual time with
increased energy. The speech of a
person with a Hypomanic Episode is often
somewhat louder and more rapid than usual,
but is not typically difficult to interrupt. It may
be full of jokes, puns, plays on words, and
irrelevancies (Criterion B3). Flight of ideas is
uncommon and, if present, lasts for very
brief periods (Criterion B4).
Distractibility is often present, as evidenced by

rapid changes in speech or activity as
a result of responding to various irrelevant
external stimuli (Criterion B5). The increase in
goal-directed activity may involve planning of,
and participation in, multiple activities
(Criterion B6). These activities are often creative
and productive (e.g., writing a letter to
the editor, clearing up paperwork). Sociability is
usually increased, and there may be an
increase in sexual activity. There may be
impulsive activity such as buying sprees,
reckless driving, or foolish business investments
(Criterion B7). However, such activities
are usually organized, are not bizarre, and do not
result in the level of impairment that is
characteristic of a Manic Episode.

Associated features of a Hypomanic Episode are
similar to those for a Manic Episode.
Mood may also be characterized as dysphoric if
irritable or depressive symptoms are
more prominent than euphoria in the clinical
presentation.
Specific Culture and Age Features
Cultural considerations that were suggested for

Major Depressive Episodes are relevant
to Hypomanic Episodes as well (See linked
section). In younger (e.g., adolescent)
persons, Hypomanic Episodes may be associated
with school truancy, antisocial
behavior, school failure, or substance use.
Course
A Hypomanic Episode typically begins

suddenly, with a rapid escalation of symptoms
within a day or two. Episodes may last for
several weeks to months and are usually more
abrupt in onset and briefer than Major
Depressive Episodes. In many cases, the
Hypomanic Episode may be preceded or
followed by a Major Depressive Episode.
Studies suggest that 5%15% of individuals
with hypomania will ultimately develop a
Manic Episode.
A Hypomanic Episode must be distinguished

from a Mood Disorder Due to a General
if the mood disturbance is judged to be the direct
specific general medical condition (e.g., multiple
sclerosis, brain tumor, Cushing's
syndrome) (See linked section). This
findings, or physical examination. If it is judged
that the hypomanic symptoms are not the
direct physiological consequence of the general
medical condition, then the primary
Mood Disorder is recorded on Axis I (e.g.,
Bipolar II Disorder) and the general medical
condition is recorded on Axis III (e.g.,
myocardial infarction).

distinguished from a Hypomanic Episode
by the fact that a substance (e.g., a drug of
abuse, a medication, or exposure to a toxin)
is judged to be etiologically related to the mood
Symptoms like those seen in a Hypomanic
Episode may be precipitated by a drug of
abuse (e.g., hypomanic symptoms that occur
only in the context of intoxication with
cocaine would be diagnosed as Cocaine-Induced
Mood Disorder, With Manic Features,
With Onset During Intoxication). Symptoms like
those seen in a Hypomanic Episode may
also be precipitated by antidepressant treatment
such as medication, electroconvulsive
therapy, or light therapy. Such episodes are also
diagnosed as Substance-Induced
Mood Disorders (e.g., Amitriptyline-Induced
Mood Disorder, With Manic Features;
Disorder, With Manic Features). However,
clinical judgment is essential to determine
whether the treatment is truly causal or
whether a primary Hypomanic Episode
happened to have its onset while the person was
receiving the treatment (See linked section).
Manic Episodes should be distinguished from

Hypomanic Episodes. Although Manic
Episodes and Hypomanic Episodes have
identical lists of characteristic symptoms, the
mood disturbance in Hypomanic Episodes is not
or to require hospitalization. Some
Hypomanic Episodes may evolve into full
Manic Episodes.

Hypomanic Episode are both
Disorder is distinguished from a Hypomanic
Episode by its characteristic early onset (i.e.,
before age 7 years), chronic rather than
episodic course, lack of relatively clear onsets
and offsets, and the absence of
abnormally expansive or elevated mood.
A Hypomanic Episode must be distinguished

from euthymia, particularly in
individuals who have been chronically depressed
and are unaccustomed to the
experience of a nondepressed mood state.
Criteria for Hypomanic Episode
A. A distinct period of persistently elevated,

expansive, or irritable mood, lasting
throughout at least 4 days, that is clearly
different from the usual nondepressed
mood.
B. During the period of mood disturbance, three
(or more) of the following
symptoms have persisted (four if the mood is
only irritable) and have been
present to a significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep (e.g., feels rested
after only 3 hours of sleep)
3. more talkative than usual or pressure to keep
talking
4. flight of ideas or subjective experience that
thoughts are racing
5. distractibility (i.e., attention too easily drawn
to unimportant or irrelevant
external stimuli)
6. increase in goal-directed activity (either
socially, at work or school, or
sexually) or psychomotor agitation
7. excessive involvement in pleasurable
activities that have a high potential
for painful consequences (e.g., the person
engages in unrestrained buying
sprees, sexual indiscretions, or foolish business
investments)
C. The episode is associated with an
unequivocal change in functioning that is
uncharacteristic of the person when not
symptomatic.
D. The disturbance in mood and the change in
functioning are observable by
others.
E. The episode is not severe enough to cause
marked impairment in social or
occupational functioning, or to necessitate
hospitalization, and there are no
psychotic features.
F. The symptoms are not due to the direct
Note: Hypomanic-like episodes that are clearly
caused by somatic
antidepressant treatment (e.g., medication,
electroconvulsive therapy, light
therapy) should not count toward a diagnosis of

Bipolar II Disorder.
Depressive Disorders
Major Depressive Disorder

Diagnostic Features
The essential feature of Major Depressive

Disorder is a clinical course that is
characterized by one or more Major Depressive
Episodes (See linked section) without a
history of Manic, Mixed, or Hypomanic
Episodes (Criteria A and C). Episodes of
Substance-Induced Mood Disorder (due to the
direct physiological effects of a drug of
abuse, a medication, or toxin exposure) or of
Mood Disorder Due to a General Medical
Condition do not count toward a diagnosis of
Major Depressive Disorder. In addition, the
episodes must not be better accounted for by
Schizoaffective Disorder and are not
superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional
Disorder, or
Psychotic Disorder Not Otherwise Specified
(Criterion B).
The fourth digit in the diagnostic code for Major
Depressive Disorder indicates
whether it is a Single Episode (used only for first
episodes) or Recurrent. It is sometimes
difficult to distinguish between a single episode
with waxing and waning symptoms and
two separate episodes. For purposes of this
manual, an episode is considered to have
ended when the full criteria for the Major
Depressive Episode have not been met for at
least 2 consecutive months. During this 2-month
period, there is either complete
resolution of symptoms or the presence of
depressive symptoms that no longer meet the
full criteria for a Major Depressive Episode (In
Partial Remission).
The fifth digit in the diagnostic code for Major

Depressive Disorder indicates the
current state of the disturbance. If the criteria for
a Major Depressive Episode are met,
the severity of the episode is noted as Mild,
Moderate, Severe Without Psychotic
Features, or Severe With Psychotic Features. If
the criteria for a Major Depressive
Episode are not currently met, the fifth digit is
used to indicate whether the disorder is In
Partial Remission or In Full Remission (See

linked section).
If Manic, Mixed, or Hypomanic Episodes

develop in the course of Major Depressive
Disorder, the diagnosis is changed to a Bipolar
Disorder. However, if manic or
hypomanic symptoms occur as a direct effect of
antidepressant treatment, use of other
medications, substance use, or toxin exposure,
the diagnosis of Major Depressive
Disorder remains appropriate and an additional
diagnosis of Substance-Induced Mood
Disorder, With Manic Features (or With Mixed
Features), should be noted. Similarly, if
manic or hypomanic symptoms occur as a direct
effect of a general medical condition,
the diagnosis of Major Depressive Disorder
remains appropriate and an additional
diagnosis of Mood Disorder Due to a General
Medical Condition, With Manic Features
(or With Mixed Features), should be noted.
Specifiers
If the full criteria are currently met for a Major

Depressive Episode, the following
specifiers may be used to describe the current
clinical status of the episode and to
describe features of the current episode:

Features, Severe With
Psychotic Features (See linked section)
If the full criteria are not currently met for a

Major Depressive Episode, the following
clinical status of the Major Depressive
Disorder and to describe features of the most
recent episode:
In Partial Remission, In Full Remission (See

linked section)
The following specifiers may be used to indicate

the pattern of the episodes and the
presence of interepisode symptoms for Major
Depressive Disorder, Recurrent:
Longitudinal Course Specifiers (With and
Recording Procedures
The diagnostic codes for Major Depressive

Disorder are selected as follows:

2. The fourth digit is either 2 (if there is only a
single Major Depressive Episode)
or 3 (if there are recurrent Major Depressive
Episodes).
3. If the full criteria are currently met for a
Major Depressive Episode, the fifth
digit indicates the current severity as follows: 1
for Mild severity, 2 for Moderate
severity, 3 for Severe Without Psychotic
Features, 4 for Severe With Psychotic
Features. If the full criteria are not currently met
for a Major Depressive Episode,
the fifth digit indicates the current clinical status
of the Major Depressive
Disorder as follows: 5 for In Partial Remission,
6 for In Full Remission. If the
severity of the current episode or the current
remission status of the disorder is
unspecified, then the fifth digit is 0. Other
specifiers for Major Depressive
Disorder cannot be coded.
In recording the name of a diagnosis, terms

Major Depressive Disorder, specifiers coded in
the fourth digit (e.g., Recurrent),
specifiers coded in the fifth digit (e.g., Mild,
Severe With Psychotic Features, In Partial
Remission), as many specifiers (without codes)
as apply to the current or most recent
episode (e.g., With Melancholic Features, With
Postpartum Onset), and as many
specifiers (without codes) as apply to the course
of episodes (e.g., With Full Interepisode
Recovery); for example, 296.32 Major
Depressive Disorder, Recurrent, Moderate, With
Atypical Features, With Seasonal Pattern, With
Full Interepisode Recovery.

disorders. Major Depressive Disorder
is associated with high mortality. Up to 15% of

individuals with severe Major Depressive
Disorder die by suicide. Epidemiological
evidence also suggests that there is a fourfold
increase in death rates in individuals with Major
Depressive Disorder who are over age
55 years. Individuals with Major Depressive
Disorder admitted to nursing homes may
have a markedly increased likelihood of death in
the first year. Among individuals seen in
general medical settings, those with Major
Depressive Disorder have more pain and
physical illness and decreased physical, social,
and role functioning.
Major Depressive Disorder may be preceded by

Dysthymic Disorder (10% in
epidemiological samples and 15%25% in
clinical samples). It is also estimated that
each year approximately 10% of individuals
with Dysthymic Disorder alone will go on to
have a first Major Depressive Episode. Other
mental disorders frequently co-occur with
Major Depressive Disorder (e.g., Substance-
Related Disorders, Panic Disorder,
Obsessive-Compulsive Disorder, Anorexia
Nervosa, Bulimia Nervosa, Borderline
Personality Disorder).
Associated laboratory findings. The laboratory
abnormalities that are associated with
Major Depressive Disorder are those associated
with Major Depressive Episode (See
linked section). None of these findings are
diagnostic of Major Depressive Disorder, but
they have been noted to be abnormal in groups
Disorder compared with control subjects.
Neurobiological disturbances such as elevated
glucocorticoid levels and EEG sleep alterations
are more prevalent among individuals
with Psychotic Features and those with more
severe episodes or with Melancholic
Features. Most laboratory abnormalities are state
dependent (i.e., are present only when
depressive symptoms are present). However,
evidence suggests that some sleep EEG
abnormalities persist into clinical remission or
may precede the onset of the Major
Depressive Episode.
Associated physical examination findings and
general medical
conditions. Individuals with chronic or severe
general medical conditions are at
increased risk to develop Major Depressive
Disorder. Up to 20%25% of individuals with
certain general medical conditions (e.g.,
diabetes, myocardial infarction, carcinomas,
stroke) will develop Major Depressive Disorder
during the course of their general medical
condition. The management of the general
medical condition is more complex and the
prognosis is less favorable if Major Depressive
Disorder is present. In addition, the
prognosis of Major Depressive Disorder is
adversely affected (e.g., longer episodes or
poorer responses to treatment) by concomitant

chronic general medical conditions.
Specific culture-related features are discussed in

the text for Major Depressive Episode
(See linked section). Epidemiological studies
suggest significant cohort effects in risk of
depression. For example, individuals born
between 1940 and 1950 appear to have an
earlier age at onset and a greater lifetime risk of
depression than those born prior to
1940. There is some evidence that Atypical
Features are more common in younger
people and that Melancholic Features are more
common in older depressed people.
Among those with an onset of depression in later
life, there is evidence of subcortical
white matter hyperintensities associated with
cerebrovascular disease. These "vascular"
depressions are associated with greater
neuropsychological impairments and poorer
responses to standard therapies. Major
Depressive Disorder (Single or Recurrent) is
twice as common in adolescent and adult
females as in adolescent and adult males. In
prepubertal children, boys and girls are equally
affected.
Prevalence
Studies of Major Depressive Disorder have

reported a wide range of values for the
proportion of the adult population with the
disorder. The lifetime risk for Major Depressive
Disorder in community samples has varied from
10% to 25% for women and from 5% to
12% for men. The point prevalence of Major
Depressive Disorder in adults in community
samples has varied from 5% to 9% for women
and from 2% to 3% for men. The
prevalence rates for Major Depressive Disorder
appear to be unrelated to ethnicity,
education, income, or marital status.
Course
Major Depressive Disorder may begin at any
age, with an average age at onset in the
mid-20s. Epidemiological data suggest that the
age at onset is decreasing for those born
more recently. The course of Major Depressive
Disorder, Recurrent, is variable. Some
people have isolated episodes that are separated
by many years without any depressive
symptoms, whereas others have clusters of
episodes, and still others have increasingly
frequent episodes as they grow older. Some
evidence suggests that the periods of
remission generally last longer early in the

course of the disorder. The number of prior
episodes predicts the likelihood of developing a
subsequent Major Depressive Episode.
At least 60% of individuals with Major
Depressive Disorder, Single Episode, can be
expected to have a second episode. Individuals
who have had two episodes have a 70%
chance of having a third, and individuals who
have had three episodes have a 90%
chance of having a fourth. About 5%10% of
individuals with Major Depressive Disorder,
Single Episode, subsequently develop a Manic
Episode (i.e., develop Bipolar I Disorder).
Major Depressive Episodes may end completely

(in about two-thirds of cases), or only
partially or not at all (in about one-third of
cases). For individuals who have only partial
remission, there is a greater likelihood of
developing additional episodes and of
continuing the pattern of partial interepisode
recovery. The longitudinal course specifiers
With Full Interepisode Recovery and Without
Full Interepisode Recovery (See linked
section) may therefore have prognostic value. A
number of individuals have preexisting
Dysthymic Disorder prior to the onset of Major
Depressive Disorder, Single Episode.
Some evidence suggests that these individuals
are more likely to have additional Major
Depressive Episodes, have poorer interepisode
recovery, and may require additional
acute-phase treatment and a longer period of
continuing treatment to attain and maintain
a more thorough and longer-lasting euthymic
state.
Follow-up naturalistic studies suggested that 1

year after the diagnosis of a Major
Depressive Episode, 40% of individuals still
have symptoms that are sufficiently severe
to meet criteria for a full Major Depressive
Episode, roughly 20% continue to have some
symptoms that no longer meet full criteria for a
Major Depressive Episode (i.e., Major
Depressive Disorder, In Partial Remission), and
40% have no Mood Disorder. The
severity of the initial Major Depressive Episode
appears to predict persistence. Chronic
general medical conditions are also a risk factor
for more persistent episodes.
Episodes of Major Depressive Disorder often

follow a severe psychosocial stressor,
such as the death of a loved one or divorce.
Studies suggest that psychosocial events
(stressors) may play a more significant role in
the precipitation of the first or second
episodes of Major Depressive Disorder and may
play less of a role in the onset of
subsequent episodes. Chronic general medical
conditions and Substance Dependence
(particularly Alcohol or Cocaine Dependence)
may contribute to the onset or
exacerbation of Major Depressive Disorder.
It is difficult to predict whether the first episode

of a Major Depressive Disorder in a
young person will ultimately evolve into a
Bipolar Disorder. Some data suggest that the
acute onset of severe depression, especially with
psychotic features and psychomotor
retardation, in a young person without
prepubertal psychopathology is more likely to
predict a bipolar course. A family history of

Bipolar Disorder may also be suggestive of
subsequent development of Bipolar Disorder.
Familial Pattern
Major Depressive Disorder is 1.53 times more

common among first-degree biological
relatives of persons with this disorder than
among the general population. There is
evidence for an increased risk of Alcohol
Dependence in adult first-degree biological
relatives, and there may be an increased
incidence of an Anxiety Disorder (e.g., Panic
Disorder, Social Phobia) or
Attention-Deficit/Hyperactivity Disorder in the
children of
adults with Major Depressive Disorder.
See the "Differential Diagnosis" section for

Major Depressive Episode (See linked
section). A history of a Manic, Mixed, or
Hypomanic Episode precludes the diagnosis
of Major Depressive Disorder. The presence of
Hypomanic Episodes (without any history
of Manic Episodes) indicates a diagnosis of
Bipolar II Disorder. The presence of Manic
or Mixed Episodes (with or without Hypomanic
Episodes) indicates a diagnosis of Bipolar
I Disorder.
Major Depressive Episodes in Major Depressive

Disorder must be distinguished from
a Mood Disorder Due to a General Medical
Condition. The diagnosis is Mood
Disorder Due to a General Medical Condition if
the mood disturbance is judged to be the
direct physiological consequence of a specific
general medical condition (e.g., multiple
sclerosis, stroke, hypothyroidism) (See linked
section). This determination is based on
the history, laboratory findings, or physical
examination. If it is judged that the depressive
Axis I (e.g., Major Depressive Disorder)
Axis III (e.g., myocardial infarction).
This would be the case, for example, if the
Major Depressive Episode is considered to
be the psychological consequence of having the
general medical condition or if there is
no etiological relationship between the Major
Depressive Episode and the general
medical condition.

distinguished from Major Depressive
Episodes in Major Depressive Disorder by the
fact that a substance (e.g., a drug of
abuse, a medication, or exposure to a toxin) is

judged to be etiologically related to the
mood disturbance (See linked section). For
example, depressed mood that occurs only
in the context of withdrawal from cocaine would
Disorder, With Depressive Features, With Onset
During Withdrawal.
Dysthymic Disorder and Major Depressive

Disorder are differentiated based on
severity, chronicity, and persistence. In Major
Depressive Disorder, the depressed mood
must be present for most of the day, nearly every
day, for a period of at least 2 weeks,
whereas Dysthymic Disorder must be present for
more days than not over a period of at
least 2 years. The differential diagnosis between
Dysthymic Disorder and Major
Depressive Disorder is made particularly
difficult by the fact that the two disorders share
similar symptoms and that the differences
between them in onset, duration, persistence,
and severity are not easy to evaluate
retrospectively. Usually Major Depressive
Disorder
consists of one or more discrete Major
Depressive Episodes that can be distinguished
from the person's usual functioning, whereas
Dysthymic Disorder is characterized by
chronic, less severe depressive symptoms that
have been present for many years. If the
initial onset of chronic depressive symptoms is
of sufficient severity and number to meet
criteria for a Major Depressive Episode, the
diagnosis would be Major Depressive
Disorder, Chronic (if the criteria are still met), or
Major Depressive Disorder, In Partial
Remission (if the criteria are no longer met). The
diagnosis of Dysthymic Disorder is
made following Major Depressive Disorder only
if the Dysthymic Disorder was
established prior to the first Major Depressive
Episode (i.e., no Major Depressive
Episodes during the first 2 years of dysthymic
symptoms), or if there has been a full
remission of the Major Depressive Episode (i.e.,
lasting at least 2 months) before the
onset of the Dysthymic Disorder.
Schizoaffective Disorder differs from Major

Depressive Disorder, With Psychotic
Features, by the requirement that in
Schizoaffective Disorder there must be at least 2
weeks of delusions or hallucinations occurring
in the absence of prominent mood
symptoms. Depressive symptoms may be
present during Schizophrenia, Delusional
Disorder, and Psychotic Disorder Not Otherwise
Specified. Most commonly, such
depressive symptoms can be considered
associated features of these disorders and do
not merit a separate diagnosis. However, when
the depressive symptoms meet full
criteria for a Major Depressive Episode (or are
of particular clinical significance), a
diagnosis of Depressive Disorder Not Otherwise
Specified may be made in addition to
the diagnosis of Schizophrenia, Delusional
Disorder, or Psychotic Disorder Not
Otherwise Specified. Schizophrenia, Catatonic
Type, may be difficult to distinguish from
Major Depressive Disorder, With Catatonic
Features. Prior history or family history may
be helpful in making this distinction.
In elderly individuals, it is often difficult to

determine whether cognitive symptoms
(e.g., disorientation, apathy, difficulty
concentrating, memory loss) are better
accounted
for by a dementia or by a Major Depressive
Episode in Major Depressive Disorder. This
differential diagnosis may be informed by a
thorough general medical evaluation and
consideration of the onset of the disturbance,
temporal sequencing of depressive and
cognitive symptoms, course of illness, and
treatment response. The premorbid state of
the individual may help to differentiate a Major
Depressive Disorder from dementia. In
dementia, there is usually a premorbid history of
declining cognitive function, whereas
the individual with Major Depressive Disorder is
much more likely to have a relatively
normal premorbid state and abrupt cognitive
decline associated with the depression.
Diagnostic Criteria for 296.2x Major

Depressive
Disorder, Single Episode
A. Presence of a single Major Depressive
Episode (See linked section).
B. The Major Depressive Episode is not better
accounted for by Schizoaffective
Disorder and is not superimposed on
Schizophrenia, Schizophreniform
Disorder, Delusional Disorder, or Psychotic
Disorder Not Otherwise Specified.
C. There has never been a Manic Episode (See
linked section), a Mixed
Episode (See linked section), or a Hypomanic
Note: This exclusion does not apply if all of the
manic-like, mixed-like, or
hypomanic-like episodes are substance or
treatment induced or are due to the
direct physiological effects of a general medical
condition.

Depressive Episode, specify its current
clinical status and/or features:
Features/Severe With Psychotic
Features (See linked section)

Major Depressive Episode, specify the
current clinical status of the Major Depressive
Disorder or features of the most recent
episode:

linked section)
Diagnostic Criteria for 296.3x Major

Depressive
Disorder, Recurrent
A. Presence of two or more Major Depressive

Episodes (See linked section).
Note: To be considered separate episodes, there
must be an interval of at least
2 consecutive months in which criteria are not
met for a Major Depressive
Episode.
B. The Major Depressive Episodes are not better
accounted for by
Otherwise Specified.
Note: This exclusion does not apply if all of the
manic-like, mixed-like, or
hypomanic-like episodes are substance or
treatment induced or are due to the
direct physiological effects of a general medical
condition.

Depressive Episode, specify its current

Major Depressive Episode, specify the
current clinical status of the Major Depressive
Disorder or features of the most recent
episode:

linked section)
Specify:
Without Interepisode Recovery)
300.4 Dysthymic Disorder
Diagnostic Features
The essential feature of Dysthymic Disorder is a

chronically depressed mood that occurs
for most of the day more days than not for at
least 2 years (Criterion A). Individuals with
Dysthymic Disorder describe their mood as sad
or "down in the dumps." In children, the
mood may be irritable rather than depressed, and
the required minimum duration is only
1 year. During periods of depressed mood, at
least two of the following additional
symptoms are present: poor appetite or
overeating, insomnia or hypersomnia, low
energy or fatigue, low self-esteem, poor
concentration or difficulty making decisions,
and
feelings of hopelessness (Criterion B).
Individuals may note the prominent presence of
low interest and self-criticism, often seeing
themselves as uninteresting or incapable.
Because these symptoms have become so much
a part of the individual's day-to-day
experience (e.g., "I've always been this way,"
"That's just how I am"), they are often not
reported unless directly asked about by the
interviewer.
During the 2-year period (1 year for children or

adolescents), any symptom-free
intervals last no longer than 2 months (Criterion
C). The diagnosis of Dysthymic Disorder
can be made only if the initial 2-year period of
dysthymic symptoms is free of Major
Depressive Episodes (Criterion D). If the
chronic depressive symptoms include a Major
Depressive Episode during the initial 2 years,
then the diagnosis is Major Depressive
Disorder, Chronic (if full criteria for a Major
Depressive Episode are met), or Major
Depressive Disorder, In Partial Remission (if
full criteria for a Major Depressive Episode
are not currently met). After the initial 2 years of
the Dysthymic Disorder, Major
Depressive Episodes may be superimposed on
the Dysthymic Disorder. In such cases
("double depression"), both Major Depressive
Disorder and Dysthymic Disorder are
diagnosed. Once the person returns to a
dysthymic baseline (i.e., criteria for a Major
Depressive Episode are no longer met but
dysthymic symptoms persist), only Dysthymic
Disorder is diagnosed.
The diagnosis of Dysthymic Disorder is not

made if the individual has ever had a
Manic Episode (See linked section), a Mixed
Episode (See linked section), or a
Hypomanic Episode (See linked section) or if
criteria have ever been met for
Cyclothymic Disorder (Criterion E). A separate
diagnosis of Dysthymic Disorder is not
made if the depressive symptoms occur
exclusively during the course of a chronic
Psychotic Disorder, such as Schizophrenia or
Delusional Disorder (Criterion F), in which
case they are regarded as associated features of
these disorders. Dysthymic Disorder is
also not diagnosed if the disturbance is due to
the direct physiological effects of a
substance (e.g., alcohol, antihypertensive
medications) or a general medical condition
(e.g., hypothyroidism, Alzheimer's disease)
(Criterion G). The symptoms must cause
clinically significant distress or impairment in
social, occupational (or academic), or other
important areas of functioning (Criterion H).
Specifiers
Age at onset and the characteristic pattern of

symptoms in Dysthymic Disorder may be
indicated by using the following specifiers:
Early Onset. This specifier should be used if the
onset of the dysthymic
symptoms occurs before age 21 years. Such
individuals are more likely to
develop subsequent Major Depressive Episodes.
Late Onset. This specifier should be used if the
onset of the dysthymic
symptoms occurs at age 21 or older.
With Atypical Features. This specifier should be
used if the pattern of
symptoms during the most recent 2 years of the
disorder meets the criteria for
With Atypical Features (See linked section).

disorders. The associated features of
Dysthymic Disorder are similar to those for a
Major Depressive Episode (See linked
section). Several studies suggest that the most
commonly encountered symptoms in
Dysthymic Disorder may be feelings of
inadequacy; generalized loss of interest or
pleasure; social withdrawal; feelings of guilt or
brooding about the past; subjective
feelings of irritability or excessive anger; and
decreased activity, effectiveness, or
productivity. (Appendix B provides an
alternative for Criterion B for use in research
studies that includes these items.) In individuals
with Dysthymic Disorder, vegetative
symptoms (e.g., sleep, appetite, weight change,
and psychomotor symptoms) appear to
be less common than for persons in a Major

Depressive Episode. When Dysthymic
Disorder without prior Major Depressive
Disorder is present, it is a risk factor for
developing Major Depressive Disorder (in
clinical settings up to 75% of individuals with
Dysthymic Disorder will develop Major
Depressive Disorder within 5 years). Dysthymic
Disorder may be associated with Borderline,
Histrionic, Narcissistic, Avoidant, and
Dependent Personality Disorders. However, the
assessment of features of a Personality
Disorder is difficult in such individuals because
chronic mood symptoms may contribute
to interpersonal problems or be associated with
distorted self-perception. Other chronic
Axis I disorders (e.g., Substance Dependence) or
chronic psychosocial stressors may be
associated with Dysthymic Disorder in adults. In
children, Dysthymic Disorder may be
associated with Attention-Deficit/Hyperactivity
Disorder, Conduct Disorder, Anxiety
Disorders, Learning Disorders, and Mental
Retardation.
Associated laboratory findings. About

25%50% of adults with Dysthymic Disorder
have some of the same polysomnographic
features that are found in some individuals
with Major Depressive Disorder (e.g., reduced
rapid eye movement [REM] latency,
increased REM density, reduced slow-wave
sleep, impaired sleep continuity). Those
individuals with polysomnographic
abnormalities more often have a positive family
history for Major Depressive Disorder (and may
respond better to antidepressant
medications) than those with Dysthymic
Disorder without such findings. Whether
polysomnographic abnormalities are also found
in those with "pure" Dysthymic Disorder
(i.e., those with no prior history of Major
Depressive Episodes) is not clear.
Dexamethasone nonsuppression in Dysthymic
Disorder is not common, unless criteria
are also met for a Major Depressive Episode.
Specific Age and Gender Features

In children, Dysthymic Disorder seems to occur
equally in both sexes and often results in
impaired school performance and social
interaction. Children and adolescents with
Dysthymic Disorder are usually irritable and
cranky as well as depressed. They have low
self-esteem and poor social skills and are
pessimistic. In adulthood, women are two to
three times more likely to develop Dysthymic
Disorder than are men.
Prevalence
The lifetime prevalence of Dysthymic Disorder

(with or without superimposed Major
Depressive Disorder) is approximately 6%. The
point prevalence of Dysthymic Disorder
is approximately 3%.
Course
Dysthymic Disorder often has an early and
insidious onset (i.e., in childhood,
adolescence, or early adult life) as well as a
chronic course. In clinical settings,
individuals with Dysthymic Disorder usually
have superimposed Major Depressive
Disorder, which is often the reason for seeking
treatment. If Dysthymic Disorder
precedes the onset of Major Depressive
Disorder, there is less likelihood that there will
be spontaneous full interepisode recovery
between Major Depressive Episodes and a
greater likelihood of having more frequent
subsequent episodes. Although the
spontaneous remission rate for Dysthymic
Disorder may be as low as 10% per year,
evidence suggests the outcome is significantly
better with active treatment. The treated
course of Dysthymic Disorder appears similar to
that of other Depressive Disorders,
whether or not there is a superimposed Major
Depressive Disorder.
Familial Pattern
Dysthymic Disorder is more common among

first-degree biological relatives of people
with Major Depressive Disorder than among the
general population. In addition, both
Disorder are more common in the first-degree
relatives of individuals with Dysthymic
Disorder.
See the "Differential Diagnosis" section for

Major Depressive Disorder (See linked
section). The differential diagnosis between
Disorder is made particularly difficult by the
facts that the two disorders share similar
symptoms and that the differences between them
in onset, duration, persistence, and
severity are not easy to evaluate retrospectively.
Usually Major Depressive Disorder
consists of one or more discrete Major
Depressive Episodes that can be distinguished
from the person's usual functioning, whereas
Dysthymic Disorder is characterized by
chronic, less severe depressive symptoms that
have been present for many years.
When Dysthymic Disorder is of many years'

duration, the mood disturbance may not be
easily distinguished from the person's "usual"
functioning. If the initial onset of chronic
depressive symptoms is of sufficient severity
and number to meet full criteria for a Major
Depressive Episode, the diagnosis would be
Major Depressive Disorder, Chronic (if the
full criteria are still met), or Major Depressive
Disorder, In Partial Remission (if the full
criteria are no longer met). The diagnosis of
Dysthymic Disorder can be made following
Major Depressive Disorder only if the
Dysthymic Disorder was established prior to the
first Major Depressive Episode (i.e., no Major
Depressive Episodes during the first 2
years of dysthymic symptoms), or if there has
been a full remission of the Major
Depressive Disorder (i.e., lasting at least 2
months) before the onset of the Dysthymic
Disorder.
Depressive symptoms may be a common

associated feature of chronic Psychotic
Disorders (e.g., Schizoaffective Disorder,
Schizophrenia, Delusional Disorder). A
separate diagnosis of Dysthymic Disorder is not
made if the symptoms occur only during
the course of the Psychotic Disorder (including
residual phases).
Dysthymic Disorder must be distinguished from

a Mood Disorder Due to a General
Disorder Due to a General Medical
Condition, With Depressive Features, if the
mood disturbance is judged to be the direct
physiological consequence of a specific, usually
chronic, general medical condition (e.g.,
multiple sclerosis) (See linked section). This
determination is based on the history,
laboratory findings, or physical examination. If
it is judged that the depressive symptoms
are not the direct physiological consequence of
the general medical condition, then the
primary Mood Disorder is recorded on Axis I
(e.g., Dysthymic Disorder) and the general
medical condition is recorded on Axis III (e.g.,
diabetes mellitus). This would be the case,
for example, if the depressive symptoms are
considered to be the psychological
consequence of having a chronic general
medical condition or if there is no etiological
relationship between the depressive symptoms
and the general medical condition. A
Substance-Induced Mood Disorder is
distinguished from a Dysthymic Disorder by the
Often there is evidence of a coexisting

personality disturbance. When an
individual's presentation meets the criteria for
both Dysthymic Disorder and a Personality
Disorder, both diagnoses are given.
Diagnostic Criteria for 300.4 Dysthymic

Disorder
A. Depressed mood for most of the day, for

more days than not, as indicated
either by 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
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 person has never been without
the symptoms in Criteria A and
B for more than 2 months at a time.
D. No Major Depressive Episode (See linked
section) has been present during
the first 2 years of the disturbance (1 year for
children and adolescents); i.e., the
disturbance is not better accounted for by
chronic Major Depressive Disorder, or
Major Depressive Disorder, In Partial
Remission.
Note: There may have been a previous Major
Depressive Episode provided
there was a full remission (no significant signs
or symptoms for 2 months)
before development of the Dysthymic Disorder.
In addition, after the initial 2
years (1 year in children or adolescents) of
Dysthymic Disorder, there may be
superimposed episodes of Major Depressive
Disorder, in which case both
diagnoses may be given when the criteria are
met for a Major Depressive
Episode.
E. There has never been a Manic Episode (See
Episode (See linked section), and
criteria have never been met for Cyclothymic
Disorder.
F. The disturbance does not occur exclusively
during the course of a chronic
Psychotic Disorder, such as Schizophrenia or

Delusional Disorder.
G. The symptoms are not due to the direct
hypothyroidism).
H. The symptoms cause clinically significant
functioning.
Specify if:
Early Onset: if onset is before age 21 years
Late Onset: if onset is age 21 years or older
Specify (for most recent 2 years of Dysthymic
Disorder):
311 Depressive Disorder Not Otherwise
Specified
The Depressive Disorder Not Otherwise

Specified category includes disorders with
depressive features that do not meet the criteria
for Major Depressive Disorder,
Dysthymic Disorder, Adjustment Disorder With
Depressed Mood (See linked section), or
Adjustment Disorder With Mixed Anxiety and
Depressed Mood (See linked section).
Sometimes depressive symptoms can present as
part of an Anxiety Disorder Not
Otherwise Specified (See linked section).
Examples of Depressive Disorder Not
Otherwise Specified include
1. Premenstrual dysphoric disorder: in most

menstrual cycles during the past
year, symptoms (e.g., markedly depressed mood,
marked anxiety, marked
affective lability, decreased interest in activities)
regularly occurred during the
last week of the luteal phase (and remitted
within a few days of the onset of
menses). These symptoms must be severe
enough to markedly interfere with
work, school, or usual activities and be entirely
absent for at least 1 week
postmenses (See linked section for suggested
research criteria).
2. Minor depressive disorder: episodes of at least
2 weeks of depressive
symptoms but with fewer than the five items
required for Major Depressive
Disorder (See linked section for suggested
research criteria).
3. Recurrent brief depressive disorder:
depressive episodes lasting from 2 days
up to 2 weeks, occurring at least once a month
for 12 months (not associated
with the menstrual cycle) (See linked section for
suggested research criteria).
4. Postpsychotic depressive disorder of
Schizophrenia: a Major Depressive
Episode that occurs during the residual phase of
Schizophrenia (See linked
section for suggested research criteria).
5. A Major Depressive Episode superimposed on
Delusional Disorder,
Psychotic Disorder Not Otherwise Specified, or
the active phase of
Schizophrenia.
6. Situations in which the clinician has
concluded that a depressive disorder is
present but is unable to determine whether it is
primary, due to a general
medical condition, or substance induced.
Bipolar Disorders
This section includes Bipolar I Disorder, Bipolar
II Disorder, Cyclothymia, and Bipolar
Disorder Not Otherwise Specified. There are six
separate criteria sets for Bipolar I
Disorder: Single Manic Episode, Most Recent
Episode Hypomanic, Most Recent
Episode Manic, Most Recent Episode Mixed,
Most Recent Episode Depressed, and
Most Recent Episode Unspecified. Bipolar I
Disorder, Single Manic Episode, is used to
describe individuals who are having a first
episode of mania. The remaining criteria sets
are used to specify the nature of the current (or
most recent) episode in individuals who
have had recurrent mood episodes.
Bipolar I Disorder
Diagnostic Features
The essential feature of Bipolar I Disorder is a

clinical course that is characterized by the
occurrence of one or more Manic Episodes (See
linked section) or Mixed Episodes (See
linked section). Often individuals have also had
one or more Major Depressive Episodes
(See linked section). Episodes of Substance-
Induced Mood Disorder (due to the direct
effects of a medication, other somatic treatments
for depression, a drug of abuse, or
toxin exposure) or of Mood Disorder Due to a
General Medical Condition do not count
toward a diagnosis of Bipolar I Disorder. In
addition, the episodes are not better
accounted for by Schizoaffective Disorder and
are not superimposed on Schizophrenia,
Disorder, or Psychotic Disorder Not Otherwise
Specified. Bipolar I Disorder is subclassified in
the fourth digit of the code according to
whether the individual is experiencing a first
episode (i.e., Single Manic Episode) or
whether the disorder is recurrent. Recurrence is
indicated by either a shift in the polarity
of the episode or an interval between episodes of
at least 2 months without manic
symptoms. A shift in polarity is defined as a
clinical course in which a Major Depressive
Episode evolves into a Manic Episode or a
Mixed Episode or in which a Manic Episode
or a Mixed Episode evolves into a Major
Depressive Episode. In contrast, a Hypomanic
Episode that evolves into a Manic Episode or a
Mixed Episode, or a Manic Episode that
evolves into a Mixed Episode (or vice versa), is
considered to be only a single episode.
For recurrent Bipolar I Disorders, the nature of

the current (or most recent) episode can
be specified (Most Recent Episode Hypomanic,
Most Recent Episode Manic, Most
Recent Episode Mixed, Most Recent Episode
Depressed, Most Recent Episode
Unspecified).
Specifiers
If the full criteria are currently met for a Manic,
Mixed, or Major Depressive Episode, the
following specifiers may be used to describe the
current clinical status of the episode
and to describe features of the current episode:


Manic, Mixed or Major Depressive
Episode, the following specifiers may be used to
describe the current clinical status of
the Bipolar I Disorder and to describe features of
the most recent episode:

linked section)
If criteria are currently met for a Major

Depressive Episode, the following may be used
to describe features of the current episode (or, if
criteria are not currently met but the
most recent episode of Bipolar I Disorder was a
Major Depressive Episode, these
specifiers apply to that episode):

The following specifiers can be used to indicate

the pattern of episodes:

With Seasonal Pattern (applies only to the
pattern of Major Depressive
Episodes) (See linked section)

The diagnostic codes for Bipolar I Disorder are

selected as follows:

2. The fourth digit is 0 if there is a single Manic
Episode. For recurrent episodes,
the fourth digit indicates the nature of the
current episode (or, if the Bipolar I
Disorder is currently in partial or full remission,
the nature of the most recent
episode) as follows: 4 if the current or most
recent episode is a Hypomanic
Episode or a Manic Episode, 5 if it is a Major
Depressive Episode, 6 if it is a
Mixed Episode, and 7 if the current or most
recent episode is Unspecified.
3. The fifth digit (except for Bipolar I Disorder,
Most Recent Episode Hypomanic,
and Bipolar I Disorder, Most Recent Episode
Unspecified) indicates the severity
of the current episode if full criteria are met for a
Manic, Mixed, or Major
Depressive Episode as follows: 1 for Mild
criteria are not met for a Manic, Mixed, or Major
Depressive Episode, the fifth
digit indicates the current clinical status of the
Bipolar I Disorder as follows: 5 for
In Partial Remission, 6 for In Full Remission. If
current severity or clinical status
is unspecified, the fifth digit is 0. Other
specifiers for Bipolar I Disorder cannot be
coded. For Bipolar I Disorder, Most Recent
Episode Hypomanic, the fifth digit is
always 0. For Bipolar Disorder, Most Recent
Episode Unspecified, there is no
fifth digit.
In recording the name of a diagnosis, terms

Bipolar I Disorder, specifiers coded in the fourth
digit (e.g., Most Recent Episode Manic),
specifiers coded in the fifth digit (e.g., Mild,
Severe With Psychotic Features, In Partial
Remission), as many specifiers (without codes)
as apply to the current or most recent
episode (e.g., With Melancholic Features, With
Postpartum Onset), and as many
specifiers (without codes) as apply to the course
of episodes (e.g., With Rapid Cycling);
for example, 296.54 Bipolar I Disorder, Most
Recent Episode Depressed, Severe With
Psychotic Features, With Melancholic Features,
With Rapid Cycling.
Note that if the single episode of Bipolar I
Disorder is a Mixed Episode, the diagnosis
would be indicated as 296.0x Bipolar I Disorder,
Single Manic Episode, Mixed.

disorders. Completed suicide occurs in
10%15% of individuals with Bipolar I
Disorder. Suicidal ideation and attempts are
more
likely to occur when the individual is in a
depressive or mixed state. Child abuse, spouse
abuse, or other violent behavior may occur
during severe Manic Episodes or during
those with psychotic features. Other associated
problems include school truancy, school
failure, occupational failure, divorce, or episodic
antisocial behavior. Bipolar Disorder is
associated with Alcohol and other Substance
Use Disorders in many individuals.
Individuals with earlier onset of Bipolar I
Disorder are more likely to have a history of
current alcohol or other substance use problems.
Concomitant alcohol and other
substance use is associated with an increased
number of hospitalizations and a worse
course of illness. Other associated mental
disorders include Anorexia Nervosa, Bulimia
Nervosa, Attention-Deficit/Hyperactivity
Disorder, Panic Disorder, and Social Phobia.
Associated laboratory findings. There appear

to be no laboratory features that are
diagnostic of Bipolar I Disorder or that
distinguish Major Depressive Episodes found in
Bipolar I Disorder from those in Major
Depressive Disorder or Bipolar II Disorder.
Imaging studies comparing groups of individuals
with Bipolar I Disorder with groups with
Major Depressive Disorder or groups without
any Mood Disorder tend to show increased
rates of right-hemispheric lesions, or bilateral
subcortical or periventricular lesions in
those with Bipolar I Disorder.

general medical conditions. An
age at onset for a first Manic Episode after age
40 years should alert the clinician to the
possibility that the symptoms may be due to a
general medical condition or substance
use. Current or past hypothyroidism or
laboratory evidence of mild thyroid
hypofunction
may be associated with Rapid Cycling (See
linked section). In addition, hyperthyroidism
may precipitate or worsen manic symptoms in
individuals with a preexisting Mood
Disorder. However, hyperthyroidism in
individuals without preexisting Mood Disorder
does not typically cause manic symptoms.
There are no reports of differential incidence of

Bipolar I Disorder based on race or
ethnicity. There is some evidence that clinicians
may have a tendency to overdiagnose
Schizophrenia (instead of Bipolar Disorder) in
some ethnic groups and in younger
individuals.
Approximately 10%15% of adolescents with

recurrent Major Depressive Episodes
will go on to develop Bipolar I Disorder. Mixed
Episodes appear to be more likely in
adolescents and young adults than in older
adults.
Recent epidemiological studies in the United
States indicate that Bipolar I Disorder is
approximately equally common in men and
women (unlike Major Depressive Disorder,
which is more common in women). Gender
appears to be related to the number and type
of Manic and Major Depressive Episodes. The
first episode in males is more likely to be
a Manic Episode. The first episode in females is
more likely to be a Major Depressive
Episode. In men the number of Manic Episodes
equals or exceeds the number of Major
Depressive Episodes, whereas in women Major
Depressive Episodes predominate. In
addition, Rapid Cycling (See linked section) is
more common in women than in men.
Some evidence suggests that mixed or
depressive symptoms during Manic Episodes
may be more common in women as well,
although not all studies are in agreement.
Thus, women may be at particular risk for
depressive or intermixed mood symptoms.
Women with Bipolar I Disorder have an
increased risk of developing subsequent
episodes in the immediate postpartum period.
Some women have their first episode
during the postpartum period. The specifier With
Postpartum Onset may be used to
indicate that the onset of the episode is within 4
weeks of delivery (See linked section).
The premenstrual period may be associated with
worsening of an ongoing Major
Depressive, Manic, Mixed, or Hypomanic
Episode.
Prevalence
The lifetime prevalence of Bipolar I Disorder in

community samples has varied from
0.4% to 1.6%.
Course
Average age at onset is 20 for both men and
women. Bipolar I Disorder is a recurrent
disordermore than 90% of individuals who
have a single Manic Episode go on to have
future episodes. Roughly 60%70% of Manic
Episodes occur immediately before or after
a Major Depressive Episode. Manic Episodes
often precede or follow the Major
Depressive Episodes in a characteristic pattern
for a particular person. The number of
lifetime episodes (both Manic and Major
Depressive) tends to be higher for Bipolar I
Disorder compared with Major Depressive
Disorder, Recurrent. Studies of the course of
Bipolar I Disorder prior to lithium maintenance
treatment suggest that, on average, four
episodes occur in 10 years. The interval between
episodes tends to decrease as the
individual ages. There is some evidence that
changes in sleep-wake schedule such as
occur during time zone changes or sleep
deprivation may precipitate or exacerbate a
Manic, Mixed, or Hypomanic Episode.
Approximately 5%15% of individuals with
Bipolar
I Disorder have multiple (four or more) mood
episodes (Major Depressive, Manic, Mixed,
or Hypomanic) that occur within a given year. If
this pattern is present, it is noted by the
specifier With Rapid Cycling (See linked
section). A rapid-cycling pattern is associated
with a poorer prognosis.
Although the majority of individuals with

Bipolar I Disorder experience significant
symptom reduction between episodes, some
(20%30%) continue to display mood
lability and other residual mood symptoms. As
many as 60% experience chronic
interpersonal or occupational difficulties
between acute episodes. Psychotic symptoms
may develop after days or weeks in what was
previously a nonpsychotic Manic or Mixed
Episode. When an individual has Manic
Episodes with psychotic features, subsequent
Manic Episodes are more likely to have
psychotic features. Incomplete interepisode
recovery is more common when the current
episode is accompanied by mood-
incongruent psychotic features.
Familial Pattern
First-degree biological relatives of individuals

with Bipolar I Disorder have elevated rates of
Bipolar I Disorder (4%24%), Bipolar II
Disorder (1%5%), and Major Depressive
Disorder (4%24%). Those individuals with
Mood Disorder in their first-degree biological
relatives are more likely to have an earlier age at
onset. Twin and adoption studies provide strong
evidence of a genetic influence for Bipolar I
Disorder.
Major Depressive, Manic, Mixed, and

Hypomanic Episodes in Bipolar I Disorder must
be distinguished from episodes of a Mood
Disorder Due to a General Medical Condition.
The diagnosis is Mood Disorder Due to a
General Medical Condition for episodes that are
judged to be the direct physiological
consequence of a specific general medical
condition (e.g., multiple sclerosis, stroke,
hypothyroidism) (See linked section). This
findings, or physical examination.

distinguished from Major Depressive, Manic, or
Mixed Episodes that occur in Bipolar I Disorder
by the fact that a substance (e.g., a drug of
abuse, a medication, or exposure to a toxin) is
disturbance (See linked section). Symptoms like
those seen in a Manic, Mixed, or Hypomanic
Episode may be part of an intoxication with or
withdrawal from a drug of abuse and should be
diagnosed as a Substance-Induced Mood
Disorder (e.g., euphoric mood that occurs only
in the context of intoxication with cocaine would
Disorder, With Manic Features, With Onset
During Intoxication). Symptoms like those seen
in a Manic or Mixed Episode may also be
medication, electroconvulsive therapy, or light
therapy. Such episodes may be diagnosed as a
Substance-Induced Mood Disorder (e.g.,
Amitriptyline-Induced Mood Disorder, With
Manic Features; Electroconvulsive Therapy-
Induced Mood Disorder, With Manic Features)
and would not count toward a diagnosis of
Bipolar I Disorder. However, when the
substance use or medication is judged not to
fully account for the episode (e.g., the episode
continues for a considerable period
autonomously after the substance is
discontinued), the episode would count toward a
diagnosis of Bipolar I Disorder.
Bipolar I Disorder is distinguished from Major

Depressive Disorder and Dysthymic
Disorder by the lifetime history of at least one
Manic or Mixed Episode. Bipolar I
Disorder is distinguished from Bipolar II
Disorder by the presence of one or more Manic
or Mixed Episodes. When an individual
previously diagnosed with Bipolar II Disorder
develops a Manic or Mixed Episode, the
diagnosis is changed to Bipolar I Disorder.
In Cyclothymic Disorder, there are numerous

periods of hypomanic symptoms that
do not meet criteria for a Manic Episode and
periods of depressive symptoms that do not
meet symptom or duration criteria for a Major
Depressive Episode. Bipolar I Disorder is
distinguished from Cyclothymic Disorder by the
presence of one or more Manic or Mixed
Episodes. If a Manic or Mixed Episode occurs
after the first 2 years of Cyclothymic
Disorder, then Cyclothymic Disorder and
Bipolar I Disorder may both be diagnosed.
The differential diagnosis between Psychotic

Disorders (e.g., Schizoaffective
Disorder, Schizophrenia, and Delusional
Disorder) and Bipolar I Disorder may be
difficult
(especially in adolescents) because these
disorders may share a number of presenting
symptoms (e.g., grandiose and persecutory
delusions, irritability, agitation, and catatonic
symptoms), particularly cross-sectionally and
early in their course. In contrast to Bipolar I
Disorder, Schizophrenia, Schizoaffective
Disorder, and Delusional Disorder are all
characterized by periods of psychotic symptoms
that occur in the absence of prominent
mood symptoms. Other helpful considerations
include the accompanying symptoms,
previous course, and family history. Manic and
depressive symptoms may be present
during Schizophrenia, Delusional Disorder, and
Psychotic Disorder Not Otherwise
Specified, but rarely with sufficient number,
duration, and pervasiveness to meet criteria
for a Manic Episode or a Major Depressive
Episode. However, when full criteria are met
(or the symptoms are of particular clinical
significance), a diagnosis of Bipolar Disorder
Not Otherwise Specified may be made in
addition to the diagnosis of Schizophrenia,
Delusional Disorder, or Psychotic Disorder Not
If there is a very rapid alternation (over days)

between manic symptoms and
depressive symptoms (e.g., several days of
purely manic symptoms followed by several
days of purely depressive symptoms) that do not
meet minimal duration criteria for a
Manic Episode or Major Depressive Episode,
the diagnosis is Bipolar Disorder Not
Diagnostic Criteria for 296.0x Bipolar I

Disorder, Single
Manic Episode
A. Presence of only one Manic Episode (See
linked section) and no past Major
Depressive Episodes.
Note: Recurrence is defined as either a change in
polarity from depression or an
interval of at least 2 months without manic
symptoms.
B. The Manic Episode is not better accounted
for by Schizoaffective Disorder
and is not superimposed on Schizophrenia,
Schizophreniform Disorder,
Delusional Disorder, or Psychotic Disorder Not
Specify if:
Mixed: if symptoms meet criteria for a Mixed
Episode (See linked section)
If the full criteria are currently met for a Manic,
Mixed, or Major Depressive
Episode, specify its current clinical status and/or
features:
Manic, Mixed, or Major Depressive
Episode, specify the current clinical status of the
Bipolar I Disorder or features of
the most recent episode:
linked section)
Diagnostic Criteria for 296.40 Bipolar I

Disorder, Most
Recent Episode Hypomanic
A. Currently (or most recently) in a Hypomanic

B. There has previously been at least one Manic
Episode (See linked section) or
C. The mood symptoms cause clinically
significant distress or impairment in
social, occupational, or other important areas of
functioning.
D. The mood episodes in Criteria A and B are
not better accounted for by
Specify:
Disorder, Most
Recent Episode Manic
A. Currently (or most recently) in a Manic

B. There has previously been at least one Major
Depressive Episode (See
linked section), Manic Episode (See linked
section), or Mixed Episode (See
linked section).
C. The mood episodes in Criteria A and B are
If the full criteria are currently met for a Manic
Episode, specify its current
Manic Episode, specify the current
clinical status of the Bipolar I Disorder and/or
features of the most recent Manic
Episode:
linked section)
Specify:
Disorder, Most
Recent Episode Mixed
A. Currently (or most recently) in a Mixed

B. There has previously been at least one Major
Depressive Episode (See
linked section), Manic Episode (See linked
section), or Mixed Episode (See
linked section).
If the full criteria are currently met for a Mixed
Episode, specify its current
Mixed Episode, specify the current
clinical status of the Bipolar I Disorder and/or
features of the most recent Mixed
Episode:
linked section)
Specify:

Disorder, Most
Recent Episode Depressed
A. Currently (or most recently) in a Major

Depressive Episode (See linked
section).
Depressive Episode, specify its
current clinical status and/or features:
Major Depressive Episode, specify
the current clinical status of the Bipolar I
Disorder and/or features of the most
recent Major Depressive Episode:
linked section)
Specify:
Diagnostic Criteria for 296.7 Bipolar I

Disorder, Most
Recent Episode Unspecified
A. Criteria, except for duration, are currently (or

most recently) met for a Manic
(See linked section), a Hypomanic (See linked
section), a Mixed (See linked
section), or a Major Depressive Episode (See
linked section).
C. The mood symptoms cause clinically
significant distress or impairment in
social, occupational, or other important areas of
functioning.
D. The mood symptoms in Criteria A and B are
E. The mood symptoms in Criteria A and B are
not due to the direct
physiological effects of a substance (e.g., a drug
of abuse, a medication, or
other treatment) or a general medical condition
(e.g., hyperthyroidism).
Specify:
296.89 Bipolar II Disorder (Recurrent Major

Depressive Episodes With Hypomanic
Episodes)
Diagnostic Features
The essential feature of Bipolar II Disorder is a

clinical course that is characterized by
the occurrence of one or more Major Depressive
Episodes (Criterion A) accompanied by
at least one Hypomanic Episode (Criterion B).
Hypomanic Episodes should not be
confused with the several days of euthymia that
may follow remission of a Major
Depressive Episode. The presence of a Manic or
Mixed Episode precludes the diagnosis
of Bipolar II Disorder (Criterion C). Episodes of
Substance-Induced Mood Disorder (due
to the direct physiological effects of a
medication, other somatic treatments for
depression, drugs of abuse, or toxin exposure) or
of Mood Disorder Due to a General
Medical Condition do not count toward a
diagnosis of Bipolar II Disorder. In addition, the
episodes must not be better accounted for by
Disorder, or
Psychotic Disorder Not Otherwise Specified
(Criterion D). The symptoms must cause
clinically significant distress or impairment in
social, occupational, or other important
areas of functioning (Criterion E). In some
cases, the Hypomanic Episodes themselves
do not cause impairment. Instead, the
impairment may result from the Major
Depressive
Episodes or from a chronic pattern of
unpredictable mood episodes and fluctuating
unreliable interpersonal or occupational
functioning.
Individuals with Bipolar II Disorder may not

view the Hypomanic Episodes as
pathological, although others may be troubled by
the individual's erratic behavior. Often
individuals, particularly when in the midst of a
Major Depressive Episode, do not recall
periods of hypomania without reminders from
close friends or relatives. Information from
other informants is often critical in establishing
the diagnosis of Bipolar II Disorder.
Specifiers
The following specifiers for Bipolar II Disorder
should be used to indicate the nature of
the current episode or, if the full criteria are not
currently met for a Hypomanic or Major
Depressive Episode, the nature of the most
recent episode:
Hypomanic. This specifier is used if the current

(or most recent) episode is a
Hypomanic Episode.
Depressed. This specifier is used if the current
(or most recent) episode is a
Major Depressive Episode.

Depressive Episode, the following
clinical status of the episode and to
describe features of the current episode:


Hypomanic or Major Depressive Episode,
the following specifiers may be used to describe
the current clinical status of the Bipolar
II Disorder and to describe features of the most
recent Major Depressive Episode (only if
it is the most recent type of mood episode):

linked section)
The following specifiers may be used to indicate
the pattern or frequency of episodes:

The diagnostic code for Bipolar II Disorder is

296.89; none of the specifiers are codable.
In recording the name of the diagnosis, terms
Bipolar II Disorder, specifiers indicating current
or most recent episode (e.g., Hypomanic,
Depressed), severity specifiers that apply to the
current Major Depressive Episode (e.g.,
Moderate), as many specifiers describing
features as apply to the current or most recent
Major Depressive Episode (e.g., With
Melancholic Features, With Postpartum Onset),
and as many specifiers as apply to the course of
episodes (e.g., With Seasonal Pattern);
for example, 296.89 Bipolar II Disorder,
Depressed, Severe With Psychotic Features,
With Melancholic Features, With Seasonal
Pattern.

disorders. Completed suicide (usually
during Major Depressive Episodes) is a
significant risk, occurring in 10%15% of
persons with Bipolar II Disorder. School
truancy, school failure, occupational failure, or
divorce may be associated with Bipolar II
Disorder. Associated mental disorders include
Substance Abuse or Dependence, Anorexia
Nervosa, Bulimia Nervosa, Attention-
Deficit/Hyperactivity Disorder, Panic Disorder,
Social Phobia, and Borderline Personality
Disorder.
Associated laboratory findings. There appear

to be no laboratory features that are
diagnostic of Bipolar II Disorder or that
distinguish Major Depressive Episodes found in
Bipolar II Disorder from those in Major
Depressive Disorder or Bipolar I Disorder.

general medical conditions. An age at onset for
a first Hypomanic Episode after age 40 years
should alert the clinician to the possibility that
the symptoms may be due to a general medical
condition or substance use. Current or past
hypothyroidism or laboratory evidence of mild
thyroid hypofunction may be associated with
Rapid Cycling (See linked section). In addition,
hyperthyroidism may precipitate or worsen
hypomanic symptoms in individuals with a
preexisting Mood Disorder. However,
hyperthyroidism in other individuals does not
typically cause hypomanic symptoms.
Specific Gender Features
Bipolar II Disorder may be more common in

women than in men. Gender appears to be
related to the number and type of Hypomanic
and Major Depressive Episodes. In men
the number of Hypomanic Episodes equals or
exceeds the number of Major Depressive
Episodes, whereas in women Major Depressive
Episodes predominate. In addition,
Rapid Cycling (See linked section) is more
common in women than in men. Some
evidence suggests that mixed or depressive
symptoms during Hypomanic Episodes may
be more common in women as well, although
not all studies are in agreement. Thus,
women may be at particular risk for depressive
or intermixed mood symptoms. Women
with Bipolar II Disorder may be at increased risk
of developing subsequent episodes in
the immediate postpartum period.
Prevalence
Community studies suggest a lifetime

prevalence of Bipolar II Disorder of
approximately
0.5%.
Course
Roughly 60%70% of the Hypomanic Episodes

in Bipolar II Disorder occur immediately
before or after a Major Depressive Episode.
Hypomanic Episodes often precede or
follow the Major Depressive Episodes in a
characteristic pattern for a particular person.
The number of lifetime episodes (both
Hypomanic Episodes and Major Depressive
Episodes) tends to be higher for Bipolar II
Disorder compared with Major Depressive
Disorder, Recurrent. The interval between
episodes tends to decrease as the individual
ages. Approximately 5%15% of individuals
with Bipolar II Disorder have multiple (four
or more) mood episodes (Hypomanic or Major
Depressive) that occur within a given
year. If this pattern is present, it is noted by the
specifier With Rapid Cycling (See linked
section). A rapid-cycling pattern is associated
with a poorer prognosis.
Although the majority of individuals with

Bipolar II Disorder return to a fully functional
level between episodes, approximately 15%
continue to display mood lability and
interpersonal or occupational difficulties.
Psychotic symptoms do not occur in Hypomanic
Episodes, and they appear to be less frequent in
the Major Depressive Episodes in
Bipolar II Disorder than is the case for Bipolar I
Disorder. Some evidence is consistent
with the notion that marked changes in sleep-
wake schedule such as occur during time
zone changes or sleep deprivation may
precipitate or exacerbate Hypomanic or Major
Depressive Episodes. If a Manic or Mixed
Episode develops in the course of Bipolar II
Disorder, the diagnosis is changed to Bipolar I
Disorder. Over 5 years, about 5%15% of
individuals with Bipolar II Disorder will develop
a Manic Episode.
Familial Pattern
Some studies have indicated that first-degree
biological relatives of individuals with
Bipolar II Disorder have elevated rates of
Bipolar II Disorder, Bipolar I Disorder, and
Major Depressive Disorder compared with the
general population.
Hypomanic and Major Depressive Episodes in

Bipolar II Disorder must be distinguished
from episodes of a Mood Disorder Due to a
General Medical Condition. The
diagnosis is Mood Disorder Due to a General
Medical Condition for episodes that are
judged to be the direct physiological
consequence of a specific general medical
condition
(e.g., multiple sclerosis, stroke, hypothyroidism)
(See linked section). This determination
is based on the history, laboratory findings, or
physical examination.
distinguished from Hypomanic or Major
Depressive Episodes that occur in Bipolar II
Disorder by the fact that a substance (e.g., a
drug of abuse, a medication, or exposure to a
toxin) is judged to be etiologically related
to the mood disturbance (See linked section).
Symptoms like those seen in a Hypomanic
Episode may be part of an intoxication with or
withdrawal from a drug of abuse and
should be diagnosed as a Substance-Induced
Mood Disorder (e.g., a major depressive-
like episode occurring only in the context of
withdrawal from cocaine would be diagnosed
as Cocaine-Induced Mood Disorder, With
Depressive Features, With Onset During
Withdrawal). Symptoms like those seen in a
Hypomanic Episode may also be
or light therapy. Such episodes may be
diagnosed as a Substance-Induced Mood
Disorder (e.g., Amitriptyline-Induced Mood
Disorder, With Manic Features;
Disorder, With Manic Features) and would not
count toward a diagnosis of Bipolar II Disorder.
However, when the substance use or
medication is judged not to fully account for the
episode (e.g., the episode continues for
a considerable period autonomously after the
substance is discontinued), the episode
would count toward a diagnosis of Bipolar II
Disorder.
Bipolar II Disorder is distinguished from Major

Depressive Disorder by the lifetime
history of at least one Hypomanic Episode.
Attention during the interview to whether
there is a history of euphoric or dysphoric
hypomania is important in making a differential
diagnosis. Bipolar II Disorder is distinguished
from Bipolar I Disorder by the presence
of one or more Manic or Mixed Episodes in the
latter. When an individual previously
diagnosed with Bipolar II Disorder develops a
Manic or Mixed Episode, the diagnosis is
changed to Bipolar I disorder.
In Cyclothymic Disorder, there are numerous

periods of hypomanic symptoms and
numerous periods of depressive symptoms that
do not meet symptom or duration criteria
for a Major Depressive Episode. Bipolar II
Disorder is distinguished from Cyclothymic
Disorder by the presence of one or more Major
Depressive Episodes. If a Major
Depressive Episode occurs after the first 2 years
of Cyclothymic Disorder, the additional
diagnosis of Bipolar II Disorder is given.
Bipolar II Disorder must be distinguished from

Psychotic Disorders (e.g.,
Schizoaffective Disorder, Schizophrenia, and
Delusional Disorder). Schizophrenia,
Schizoaffective Disorder, and Delusional
Disorder are all characterized by periods of
psychotic symptoms that occur in the absence of
prominent mood symptoms. Other
helpful considerations include the accompanying
symptoms, previous course, and family
history.
Diagnostic Criteria for 296.89 Bipolar II

Disorder
A. Presence (or history) of one or more Major

Depressive Episodes (See linked
section).
B. Presence (or history) of at least one
Hypomanic Episode (See linked
section).
linked section) or a Mixed
D. The mood symptoms in Criteria A and B are
E. The symptoms cause clinically significant
functioning.
Specify current or most recent episode:
Hypomanic: if currently (or most recently) in a
Hypomanic Episode (See
linked section)
Depressed: if currently (or most recently) in a
Depressive Episode, specify its
current clinical status and/or features:
Features (See linked section) Note: Fifth-digit
codes specified on See linked
section cannot be used here because the code for
Bipolar II Disorder
already uses the fifth digit.
Hypomanic or Major Depressive
Episode, specify the clinical status of the Bipolar
II Disorder and/or features of
the most recent Major Depressive Episode (only
if it is the most recent type of
mood episode):
linked section) Note: Fifth-digit
codes specified on See linked section cannot be
used here because the
code for Bipolar II Disorder already uses the
fifth digit.
Specify:
301.13
Cyclothymic Disorder
Diagnostic Features
The essential feature of Cyclothymic Disorder is

a chronic, fluctuating mood disturbance
involving numerous periods of hypomanic
symptoms (See linked section) and numerous
periods of depressive symptoms (See linked
section) (Criterion A). The hypomanic
symptoms are of insufficient number, severity,
pervasiveness, or duration to meet full
criteria for a Manic Episode, and the depressive
symptoms are of insufficient number,
severity, pervasiveness, or duration to meet full
criteria for a Major Depressive Episode.
However, it is not necessary that any of the
periods of hypomanic symptoms meet either
the duration or symptom threshold criterion for a
Hypomanic Episode. During the 2-year
period (1 year for children or adolescents), any
symptom-free intervals last no longer
than 2 months (Criterion B). The diagnosis of
Cyclothymic Disorder is made only if the
initial 2-year period of cyclothymic symptoms is
free of Major Depressive, Manic, and
Mixed Episodes (Criterion C). After the initial 2
years of the Cyclothymic Disorder, Manic
or Mixed Episodes may be superimposed on the
Cyclothymic Disorder, in which case
both Cyclothymic Disorder and Bipolar I
Disorder are diagnosed. Similarly, after the
initial 2 years of Cyclothymic Disorder, Major
Depressive Episodes may be
superimposed on the Cyclothymic Disorder, in
which case both Cyclothymic Disorder
and Bipolar II Disorder are diagnosed. The
diagnosis is not made if the pattern of mood
swings is better accounted for by
Schizoaffective Disorder or is superimposed on
a
Psychotic Disorder, such as Schizophrenia,
Disorder, or Psychotic Disorder Not Otherwise
Specified (Criterion D), in which case the
mood symptoms are considered to be associated
features of the Psychotic Disorder.
The mood disturbance must also not be due to
the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or
a general medical condition (e.g.,
hyperthyroidism) (Criterion E). Although some
people may function particularly well
during some of the periods of hypomania,
overall there must be clinically significant
distress or impairment in social, occupational, or
other important areas of functioning as
a result of the mood disturbance (Criterion F).
The impairment may develop as a result of
prolonged periods of cyclical, often
unpredictable mood changes (e.g., the person
may
be regarded as temperamental, moody,
unpredictable, inconsistent, or unreliable).

disorders. Substance-Related
Disorders and Sleep Disorders (i.e., difficulties
in initiating and maintaining sleep) may
be present.
Specific Age and Gender Features
Cyclothymic Disorder often begins early in life

and is sometimes considered to reflect a
temperamental predisposition to other Mood
Disorders (especially Bipolar Disorders). In
community samples, Cyclothymic Disorder is
apparently equally common in men and in
women. In clinical settings, women with
Cyclothymic Disorder may be more likely to
present for treatment than men.
Prevalence
Studies have reported a lifetime prevalence of

Cyclothymic Disorder of from 0.4% to 1%.
Prevalence in mood disorders clinics may range
from 3% to 5%.
Course
Cyclothymic Disorder usually begins in

adolescence or early adult life. Onset of
Cyclothymic Disorder late in adult life may
suggest a Mood Disorder Due to a General
Medical Condition such as multiple sclerosis.
Cyclothymic Disorder usually has an
insidious onset and a chronic course. There is a
15%50% risk that the person will
subsequently develop Bipolar I or II Disorder.
Familial Pattern
Major Depressive Disorder and Bipolar I or II

Disorder appear to be more common
among first-degree biological relatives of
persons with Cyclothymic Disorder than among
the general population. There may also be an

increased familial risk of Substance-
Related Disorders. In addition, Cyclothymic
Disorder may be more common in the first-
degree biological relatives of individuals with
Bipolar I Disorder.
Cyclothymic Disorder must be distinguished

from a Mood Disorder Due to a General
Condition, With Mixed Features, when the
mood disturbance is judged to be the direct
physiological consequence of a specific, usually
chronic general medical condition (e.g.,
hyperthyroidism) (See linked section). This
determination is based on the history,
laboratory findings, or physical examination. If
it is judged that the depressive symptoms
are not the direct physiological consequence of
the general medical condition, then the
primary Mood Disorder is recorded on Axis I
(e.g., Cyclothymic Disorder) and the
general medical condition is recorded on Axis
III. This would be the case, for example, if
the mood symptoms are considered to be the
psychological consequence of having a
chronic general medical condition or if there is
no etiological relationship between the
mood symptoms and the general medical
condition.
distinguished from Cyclothymic Disorder by
the fact that a substance (especially stimulants)
is judged to be etiologically related to
the mood disturbance (See linked section). The
frequent mood swings that are
suggestive of Cyclothymic Disorder usually
dissipate following cessation of drug use.
Bipolar I Disorder, With Rapid Cycling, and

Bipolar II Disorder, With Rapid
Cycling, both may resemble Cyclothymic
Disorder by virtue of the frequent marked
shifts in mood. By definition, the mood states in
Cyclothymic Disorder do not meet the
full criteria for a Major Depressive, Manic, or
Mixed Episode, whereas the specifier With
Rapid Cycling requires that full mood episodes
be present. If a Major Depressive, Manic,
or Mixed Episode occurs during the course of an
established Cyclothymic Disorder, the
diagnosis of either Bipolar I Disorder (for a
Manic or Mixed Episode) or Bipolar II
Disorder (for a Major Depressive Episode) is
given along with the diagnosis of
Cyclothymic Disorder.
Borderline Personality Disorder is associated

with marked shifts in mood that may
suggest Cyclothymic Disorder. If the criteria are
met for each disorder, both Borderline
Personality Disorder and Cyclothymic Disorder
may be diagnosed.
Diagnostic Criteria for Cyclothymic Disorder
A. For at least 2 years, the presence of numerous

periods with hypomanic
symptoms (See linked section) and numerous
periods with depressive
symptoms that do not meet criteria for a Major
Depressive Episode. Note: In
children and adolescents, the duration must be at
least 1 year.
B. During the above 2-year period (1 year in
children and adolescents), the
person has not been without the symptoms in
Criterion A for more than 2
months at a time.
C. No Major Depressive Episode (See linked
section), Manic Episode (See
linked section), or Mixed Episode (See linked
section) has been present during
the first 2 years of the disturbance.
Note: After the initial 2 years (1 year in children
and adolescents) of Cyclothymic
Disorder, there may be superimposed Manic or
Mixed Episodes (in which case
both Bipolar I Disorder and Cyclothymic
Disorder may be diagnosed) or Major
Depressive Episodes (in which case both Bipolar
II Disorder and Cyclothymic
Disorder may be diagnosed).
D. The symptoms in Criterion A are not better
accounted for by Schizoaffective
Disorder and are not superimposed on
Schizophrenia, Schizophreniform
Disorder, Delusional Disorder, or Psychotic
Disorder Not Otherwise Specified.
E. The symptoms are not due to the direct
hyperthyroidism).
F. The symptoms cause clinically significant
functioning.
296.80 Bipolar Disorder Not Otherwise

Specified
The Bipolar Disorder Not Otherwise Specified
category includes disorders with bipolar
features that do not meet criteria for any specific
Bipolar Disorder. Examples include
1. Very rapid alternation (over days) between

manic symptoms and depressive
symptoms that meet symptom threshold criteria
but not minimal duration criteria
for Manic, Hypomanic, or Major Depressive
Episodes
2. Recurrent Hypomanic Episodes without
intercurrent depressive symptoms
3. A Manic or Mixed Episode superimposed on
Delusional Disorder, residual
Schizophrenia, or Psychotic Disorder Not
Otherwise Specified
4. Hypomanic Episodes, along with chronic
depressive symptoms, that are too
infrequent to qualify for a diagnosis of
5. Situations in which the clinician has
concluded that a Bipolar Disorder is
present but is unable to determine whether it is
primary, due to a general
medical condition, or substance induced
Other Mood Disorders
293.83 Mood Disorder Due to a General

Medical
Condition
Diagnostic Features
The essential feature of Mood Disorder Due to a

General Medical Condition is a
prominent and persistent disturbance in mood
that is judged to be due to the direct

condition. The mood disturbance may involve
depressed mood; markedly diminished interest
or pleasure; or elevated, expansive, or
irritable mood (Criterion A). Although the
clinical presentation of the mood disturbance
may resemble that of a Major Depressive,
Manic, Mixed, or Hypomanic Episode, the full
criteria for one of these episodes need not be
met; the predominant symptom type may
be indicated by using one of the following
subtypes: With Depressive Features, With
Major Depressive-Like Episode, With Manic
Features, or With Mixed Features. There
must be evidence from the history, physical
examination, or laboratory findings that the
disturbance is the direct physiological
consequence of a general medical condition
(Criterion B). The mood disturbance is not better
accounted for by another mental
disorder (e.g., Adjustment Disorder With
Depressed Mood that occurs in response to the
psychosocial stress of having the general
medical condition) (Criterion C). The diagnosis
is also not made if the mood disturbance occurs
only during the course of a delirium
(Criterion D). The mood disturbance must cause
clinically significant distress or
impairment in social, occupational, or other
important areas of functioning (Criterion E).
In some cases, the individual may still be able to
function, but only with markedly
increased effort.
In determining whether the mood disturbance is

due to a general medical condition,
the clinician must first establish the presence of
a general medical condition. Further, the
clinician must establish that the mood
disturbance is etiologically related to the general
medical condition through a physiological
mechanism. A careful and comprehensive
assessment of multiple factors is necessary to
make this judgment. Although there are
no infallible guidelines for determining whether
the relationship between the mood
disturbance and the general medical condition is
etiological, several considerations
provide some guidance in this area. One
consideration is the presence of a temporal
association between the onset, exacerbation, or
remission of the general medical
condition and that of the mood disturbance.
Evidence from the literature that suggests that
there can be a direct association between the
general medical condition in question and the
development of mood symptoms can provide a
useful context in the assessment of a particular
situation. In addition, the clinician must also
judge that the disturbance is not better accounted
for by a primary Mood Disorder, a Substance-
Induced Mood Disorder, or other primary mental
disorders (e.g., Adjustment Disorder). This
determination is explained in greater detail in the
"Mental Disorders Due to a General Medical
Condition"
section (See linked section).
In contrast to Major Depressive Disorder, Mood
Condition, With Depressive Features, appears to
be nearly equally distributed by gender.

Condition increases the risk of attempted and
completed suicide. Rates of suicide are variable
depending on the particular general
medical condition, with chronic, incurable, and
painful conditions (e.g., malignancy,
spinal cord injury, peptic ulcer disease,
Huntington's disease, acquired
immunodeficiency syndrome [AIDS], end-stage
renal disease, head injury) carrying the
greatest risk for suicide.
Subtypes
One of the following subtypes may be used to

indicate which of the following symptom
presentations predominates:
With Depressive Features. This subtype is used
if the predominant mood is
depressed, but the full criteria for a Major
Depressive Episode are not met.
With Major DepressiveLike Episode. This
subtype is used if the full criteria
(except Criterion D) for a Major Depressive
Episode (See linked section) are
met.
With Manic Features. This subtype is used if the
predominant mood is
elevated, euphoric, or irritable.
With Mixed Features. This subtype is used if the
symptoms of both mania and
depression are present but neither predominates.
In recording the diagnosis of Mood Disorder

Due to a General Medical Condition, the
clinician should note both the specific
phenomenology of the disturbance, including the
appropriate subtype, and the identified general
medical condition judged to be causing
the disturbance on Axis I (e.g., 293.83 Mood
Disorder Due to Thyrotoxicosis, With Manic
Features). The ICD-9-CM code for the general
medical condition should also be noted
on Axis III (e.g., 242.9 thyrotoxicosis). (See
Appendix G for a list of selected ICD-9-CM
diagnostic codes for general medical
conditions.)
A separate diagnosis of Mood Disorder Due to a

General Medical Condition is not
given if the depressive symptoms develop
exclusively during the course of Vascular
Dementia. In this case, the depressive symptoms
are indicated by specifying the subtype
With Depressed Mood (i.e., 290.43 Vascular
Dementia, With Depressed Mood).
Associated General Medical Conditions
A variety of general medical conditions may

cause mood symptoms. These conditions
include degenerative neurological conditions
(e.g., Parkinson's disease, Huntington's
disease), cerebrovascular disease (e.g., stroke),
metabolic conditions (e.g., vitamin B12
deficiency), endocrine conditions (e.g., hyper-
and hypothyroidism, hyper- and
hypoparathyroidism, hyper- and
hypoadrenocorticism), autoimmune conditions
(e.g.,
systemic lupus erythematosus), viral or other
infections (e.g., hepatitis, mononucleosis,
human immunodeficiency virus [HIV]), and
certain cancers (e.g., carcinoma of the
pancreas). The associated physical examination
findings, laboratory findings, and
patterns of prevalence or onset reflect the
etiological general medical condition.
Prevalence
Prevalence estimates for Mood Disorder Due to

a General Medical Condition are
confined to those presentations with depressive
features. It has been observed that
25%40% of individuals with certain
neurological conditions (including Parkinson's
disease, Huntington's disease, multiple sclerosis,
stroke, and Alzheimer's disease) will
develop a marked depressive disturbance at
some point during the course of the illness.
For general medical conditions without direct
central nervous system involvement, rates
are far more variable, ranging from more than
60% in Cushing's syndrome to less than
8% in end-stage renal disease.
A separate diagnosis of Mood Disorder Due to a

General Medical Condition is not given
if the mood disturbance occurs exclusively
during the course of a delirium. In contrast, a
diagnosis of Mood Disorder Due to a General
Medical Condition may be given in
addition to a diagnosis of dementia if the mood
symptoms are a direct etiological
consequence of the pathological process causing
the dementia and if the mood
symptoms are a prominent part of the clinical
presentation (e.g., Mood Disorder Due to
Alzheimer's Disease). Because of ICD-9-CM
coding requirements, an exception to this is
when depressive symptoms occur exclusively
during the course of Vascular Dementia.
In this case, only a diagnosis of Vascular
Dementia with the subtype With Depressed
Mood is given; a separate diagnosis of Mood

Condition is not made. If the presentation
includes a mix of different types of symptoms
(e.g., mood and anxiety), the specific mental
disorder due to a general medical condition
depends on which symptoms predominate in the
clinical picture.
If there is evidence of recent or prolonged

substance use (including medications with
psychoactive effects), withdrawal from a
substance, or exposure to a toxin, a
Substance-Induced Mood Disorder should be
considered. It may be useful to obtain a
urine or blood drug screen or other appropriate
laboratory evaluation. Symptoms that
occur during or shortly after (i.e., within 4 weeks
of) Substance Intoxication or
Withdrawal or after medication use may be
especially indicative of a Substance-Induced
Disorder, depending on the character, duration,
or amount of the substance used. If the
clinician has ascertained that the disturbance is
due to both a general medical condition
and substance use, both diagnoses (i.e., Mood
Condition and Substance-Induced Mood
Disorder) are given.

Condition must be distinguished from Major
Depressive Disorder, Bipolar I Disorder, Bipolar
II Disorder, and Adjustment
Disorder With Depressed Mood (e.g., a
maladaptive response to the stress of having a
general medical condition). In Major
Depressive, Bipolar, and Adjustment Disorders,
no
specific and direct causative physiological
mechanisms associated with a general
medical condition can be demonstrated. It is
often difficult to determine whether certain
symptoms (e.g., weight loss, insomnia, fatigue)
represent a mood disturbance or are a
direct manifestation of a general medical
condition (e.g., cancer, stroke, myocardial
infarction, diabetes). Such symptoms count
toward a diagnosis of a Major Depressive
Episode except in cases where they are clearly
and fully accounted for by a general
medical condition. If the clinician cannot
determine whether the mood disturbance is
primary, substance induced, or due to a general
medical condition, Mood Disorder Not
Otherwise Specified may be diagnosed.
Diagnostic Criteria for 293.83 Mood Disorder

Due to the General Medical Condition
A. A prominent and persistent disturbance in

mood predominates in the clinical
picture and is characterized by either (or both) of
the following:
1. depressed mood or markedly diminished
interest or pleasure in all, or
almost all, activities
2. elevated, expansive, or irritable mood
B. There is evidence from the history, physical
examination, or laboratory
findings that the disturbance is the direct
general medical condition.
C. The disturbance is not better accounted for by
another mental disorder (e.g.,
Adjustment Disorder With Depressed Mood in
response to the stress of having
a general medical condition).
D. The disturbance does not occur exclusively
during the course of a delirium.
functioning.
Specify type:
With Depressive Features: if the predominant
mood is depressed but the full
criteria are not met for a Major Depressive
Episode
With Major DepressiveLike Episode: if the full
criteria are met (except
Criterion D) for a Major Depressive Episode
With Manic Features: if the predominant mood
is elevated, euphoric, or
irritable
With Mixed Features: if the symptoms of both
mania and depression are
present but neither predominates
Coding note: Include the name of the general
medical condition on Axis I, e.g.,
293.83 Mood Disorder Due to Hypothyroidism,
With Depressive Features; also
code the general medical condition on Axis III
(see Appendix G for codes).
Coding note: If depressive symptoms occur as
part of a preexisting Vascular
Dementia, indicate the depressive symptoms by

coding the appropriate subtype,
i.e., 290.43 Vascular Dementia, With Depressed
Mood.
Substance-Induced Mood Disorder
Diagnostic Features
The essential feature of Substance-Induced

Mood Disorder is a prominent and persistent
disturbance in mood (Criterion A) that is judged
to be due to the direct physiological
effects of a substance (i.e., a drug of abuse, a
medication, other somatic treatment for
depression, or toxin exposure) (Criterion B).
Depending on the nature of the substance
and the context in which the symptoms occur
(i.e., during intoxication or withdrawal), the
disturbance may involve depressed mood or
markedly diminished interest or pleasure or
elevated, expansive, or irritable mood. Although
the clinical presentation of the mood
disturbance may resemble that of a Major
Depressive, Manic, Mixed, or Hypomanic
Episode, the full criteria for one of these
episodes need not be met. The predominant
symptom type may be indicated by using one of
the following subtypes: With Depressive
Features, With Manic Features, With Mixed
Features. The disturbance must not be
better accounted for by a Mood Disorder that is
not substance induced (Criterion C). The
diagnosis is not made if the mood disturbance
occurs only during the course of a
delirium (Criterion D). The symptoms must
cause clinically significant distress or
impairment in social, occupational, or other
important areas of functioning (Criterion E).
In some cases, the individual may still be able to
function, but only with markedly
increased effort. This diagnosis should be made
instead of a diagnosis of Substance
Intoxication or Substance Withdrawal only when
the mood symptoms are in excess of
those usually associated with the intoxication or
withdrawal syndrome and when the
mood symptoms are sufficiently severe to
warrant independent clinical attention.

distinguished from a primary Mood Disorder
by considering the onset, course, and other
factors. For drugs of abuse, there must be
evidence from the history, physical examination,
or laboratory findings of Dependence,
Abuse, intoxication, or withdrawal. Substance-
Induced Mood Disorders arise only in
association with intoxication or withdrawal
states, whereas primary Mood Disorders may
precede the onset of substance use or may occur
during times of sustained abstinence.
Because the withdrawal state for some
substances can be relatively protracted, mood
symptoms can last in an intense form for up to 4
weeks after the cessation of substance
use. Another consideration is the presence of

features that are atypical of primary Mood
Disorders (e.g., atypical age at onset or course).
For example, the onset of a Manic
Episode after age 45 years may suggest a
substance-induced etiology. In contrast,
factors that suggest that the mood symptoms are
better accounted for by a primary
Mood Disorder include persistence of mood
symptoms for a substantial period of time
(i.e., a month or more) after the end of
Substance Intoxication or acute Substance
Withdrawal; the development of mood
symptoms that are substantially in excess of
what
would be expected given the type or amount of
the substance used or the duration of
use; or a history of prior recurrent primary
episodes of Mood Disorder.
Some medications (e.g., stimulants, steroids, L-
dopa, antidepressants) or other
somatic treatments for depression (e.g.,
electroconvulsive therapy or light therapy) can
induce manic-like mood disturbances. Clinical
judgment is essential to determine
whether the treatment is truly causal or whether
a primary Mood Disorder happened to
have its onset while the person was receiving the
treatment. For example, manic
symptoms that develop in a person while he or
she is taking lithium would not be
diagnosed as Substance-Induced Mood Disorder
because lithium is not likely to induce
manic-like episodes. On the other hand, a
depressive episode that developed within the
first several weeks of beginning alpha-
methyldopa (an antihypertensive agent) in a
person with no history of Mood Disorder would
qualify for the diagnosis of Alpha-
Methyldopa-Induced Mood Disorder, With
Depressive Features. In some cases, a
previously established condition (e.g., Major
Depressive Disorder, Recurrent) can recur
while the person is coincidentally taking a
medication that has the capacity to cause
depressive symptoms (e.g., L-dopa, birth-control
pills). In such cases, the clinician must
make a judgment as to whether the medication is
causative in this particular situation.
For a more detailed discussion of Substance-
Related Disorders, See linked section.
Subtypes and Specifiers
One of the following subtypes may be used to

indicate which of the following symptom
presentations predominates:
With Depressive Features. This subtype is used

if the predominant mood is
depressed.
With Manic Features. This subtype is used if the
predominant mood is
elevated, euphoric, or irritable.
With Mixed Features. This subtype is used if the
symptoms of both mania and
depression are present but neither predominates.
The context of the development of the mood

symptoms may be indicated by using
one of the following specifiers:
With Onset During Intoxication. This specifier

should be used if criteria for
intoxication with the substance are met and the
symptoms develop during the
intoxication syndrome.
With Onset During Withdrawal. This specifier
should be used if criteria for
withdrawal from the substance are met and the
symptoms develop during, or
shortly after, a withdrawal syndrome.
The name of the Substance-Induced Mood

Disorder begins with the specific substance
or somatic treatment (e.g., cocaine,
amitriptyline, electroconvulsive therapy) that is
presumed to be causing the mood symptoms.
The diagnostic code is selected from the
listing of classes of substances provided in the
criteria set. For substances that do not fit
into any of the classes (e.g., amitriptyline) and
for other somatic treatments (e.g.,
electroconvulsive therapy), the code for "Other
Substance" should be used. In addition,
for medications prescribed at therapeutic doses,
the specific medication can be indicated
by listing the appropriate E-code (see Appendix
G). The name of the disorder (e.g.,
Cocaine-Induced Mood Disorder) is followed by
the subtype indicating the predominant
symptom presentation and the specifier
indicating the context in which the symptoms
developed (e.g., 292.84 Cocaine-Induced Mood
Disorder, With Depressive Features,
With Onset During Withdrawal). When more
than one substance is judged to play a
significant role in the development of mood
symptoms, each should be listed separately
(e.g., 292.84 Cocaine-Induced Mood Disorder,
With Manic Features, With Onset During
Withdrawal; 292.84 Light Therapy-Induced
Mood Disorder, With Manic Features). If a
substance is judged to be the etiological factor
but the specific substance or class of
substances is unknown, the category 292.84
Unknown Substance-Induced Mood
Disorder may be used.
Specific Substances
Mood Disorders can occur in association with

intoxication with the following classes of
substances: alcohol; amphetamine and related
substances; cocaine; hallucinogens;
inhalants; opioids; phencyclidine and related
substances; sedatives, hypnotics, and
anxiolytics; and other or unknown substances.

Mood Disorders can occur in association
with withdrawal from the following classes of
substances: alcohol; amphetamine and
related substances; cocaine; sedatives,
hypnotics, and anxiolytics; and other or
unknown
substances.
Some of the medications reported to evoke

mood symptoms include anesthetics,
analgesics, anticholinergics, anticonvulsants,
antihypertensives, antiparkinsonian
medications, antiulcer medications, cardiac
medications, oral contraceptives,
psychotropic medications (e.g., antidepressants,
benzodiazepines, antipsychotics,
disulfiram), muscle relaxants, steroids, and
sulfonamides. Some medications have an
especially high likelihood of producing
depressive features (e.g., high doses of
reserpine,
corticosteroids, anabolic steroids). Note that this
is not an exhaustive list of possible
medications and that many medications may
occasionally produce an idiosyncratic
depressive reaction. Heavy metals and toxins
(e.g., volatile substances such as gasoline
and paint, organophosphate insecticides, nerve
gases, carbon monoxide, carbon
dioxide) may also cause mood symptoms.
Mood symptoms occur commonly in Substance

Intoxication and Substance
Withdrawal, and the diagnosis of the substance-
specific intoxication or substance-
specific withdrawal will usually suffice to
categorize the symptom presentation. A
diagnosis of Substance-Induced Mood Disorder
should be made instead of a diagnosis
of Substance Intoxication or Substance
Withdrawal only when the mood symptoms are
judged to be in excess of those usually
associated with the intoxication or withdrawal
syndrome and when the mood symptoms are
sufficiently severe to warrant independent
clinical attention. For example, dysphoric mood
is a characteristic feature of Cocaine
Withdrawal. Cocaine-Induced Mood Disorder
should be diagnosed instead of Cocaine
Withdrawal only if the mood disturbance is
substantially more intense than what is
usually encountered with Cocaine Withdrawal
and is sufficiently severe to be a separate
focus of attention and treatment.
If substance-induced mood symptoms occur

exclusively during the course of a
delirium, the mood symptoms are considered to
be an associated feature of the delirium
and are not diagnosed separately. In substance-
induced presentations that contain a
mix of different types of symptoms (e.g., mood,
psychotic, and anxiety symptoms),
the specific type of Substance-Induced Disorder
to be diagnosed depends on which type
of symptoms predominates in the clinical
presentation.

distinguished from a primary Mood Disorder
by the fact that a substance is judged to be
etiologically related to the symptoms (See
linked section).
A Substance-Induced Mood Disorder due to a

prescribed treatment for a mental
disorder or general medical condition must have
its onset while the person is receiving
the medication (e.g., antihypertensive
medication) or during withdrawal, if there is a
withdrawal syndrome associated with the
medication. Once the treatment is
discontinued, the mood symptoms will usually
remit within days to several weeks
(depending on the half-life of the substance and
the presence of a withdrawal
syndrome). If symptoms persist beyond 4 weeks,
other causes for the mood symptoms
should be considered.
Because individuals with general medical

conditions often take medications for those
conditions, the clinician must consider the
possibility that the mood symptoms are
caused by the physiological consequences of the
general medical condition rather than
the medication, in which case Mood Disorder
Due to a General Medical Condition is
diagnosed. The history often provides the
primary basis for such a judgment. At times, a
change in the treatment for the general medical
condition (e.g., medication substitution
or discontinuation) may be needed to determine
empirically for that person whether the
medication is the causative agent. If the clinician
has ascertained that the disturbance is
due to both a general medical condition and
substance use, both diagnoses (i.e., Mood
and Substance-Induced Mood Disorder)
may be given. When there is insufficient
evidence to determine whether the mood
symptoms are due to a substance (including a
medication) or to a general medical
condition or are primary (i.e., not due to either a
substance or a general medical
condition), Depressive Disorder Not Otherwise
Specified or Bipolar Disorder Not
Otherwise Specified would be indicated.
Diagnostic Criteria for Substance-Induced

Mood
Disorder
A. A prominent and persistent disturbance in

mood predominates in the clinical
picture and is characterized by either (or both) of
the following:
1. depressed mood or markedly diminished
interest or pleasure in all, or
almost all, activities
2. elevated, expansive, or irritable mood
B. There is evidence from the history, physical
examination, or laboratory
findings of either (1) or (2):
1. the symptoms in Criterion A developed
during, or within a month of,
Substance Intoxication or Withdrawal
2. medication use is etiologically related to the
disturbance
C. The disturbance is not better accounted for by
a Mood Disorder that is not
substance induced. Evidence that the symptoms
are better accounted for by a
Mood Disorder that is not substance induced
might include the following: the
symptoms precede the onset of the substance use
(or medication use); the
symptoms persist for a substantial period of time
(e.g., about a month) after the
cessation of acute withdrawal or severe
intoxication or are substantially in
excess of what would be expected given the type
or amount of the substance
used or the duration of use; or there is other
evidence that suggests the
existence of an independent non-substance-
induced Mood Disorder (e.g., a
history of recurrent Major Depressive Episodes).
D. The disturbance does not occur exclusively
during the course of a delirium.
functioning.
Note: This diagnosis should be made instead of
a diagnosis of Substance
Intoxication or Substance Withdrawal only when
the mood symptoms are in
excess of those usually associated with the
intoxication or withdrawal syndrome
and when the symptoms are sufficiently severe
to warrant independent clinical
attention.
Code [Specific Substance]Induced Mood
Disorder:
(291.89 Alcohol; 292.84 Amphetamine [or
Amphetamine-Like Substance];
292.84 Cocaine; 292.84 Hallucinogen; 292.84
Inhalant; 292.84 Opioid;
292.84 Phencyclidine [or Phencyclidine-Like
Substance]; 292.84 Sedative,
Hypnotic, or Anxiolytic; 292.84 Other [or
Unknown] Substance)
Specify type:
With Depressive Features: if the predominant
mood is depressed
With Manic Features: if the predominant mood
is elevated, euphoric, or
irritable
With Mixed Features: if symptoms of both
mania and depression are
present and neither predominates
Specify if (see table for applicability by
substance):
With Onset During Intoxication: if the criteria
are met for Intoxication with
the substance and the symptoms develop during
the intoxication syndrome
With Onset During Withdrawal: if criteria are
met for Withdrawal from the
substance and the symptoms develop during, or
shortly after, a withdrawal
syndrome
296.90 Mood Disorder Not Otherwise Specified

This category includes disorders with mood
symptoms that do not meet the criteria for
any specific Mood Disorder and in which it is
difficult to choose between Depressive
Disorder Not Otherwise Specified and Bipolar
Disorder Not Otherwise Specified (e.g.,
acute agitation).
Specifiers Describing Current or Most Recent

Episode
A number of specifiers for Mood Disorders are

provided to increase diagnostic specificity
and create more homogeneous subgroups, assist
in treatment selection, and improve
the prediction of prognosis. The
Severity/Psychotic/Remission specifiers
describe the
current clinical status of the Mood Disorder. The
following specifiers describe symptom
or course features of the current mood episode
(or the most recent mood episode if
criteria are not currently met for any episode):
Chronic, With Catatonic Features, With
Melancholic Features, With Atypical Features,
and With Postpartum Onset. The
specifiers that indicate severity, remission, and
psychotic features can be coded in the
fifth digit of the diagnostic code for most of the
Mood Disorders. The other specifiers
cannot be coded. Table 1 indicates which
episode specifiers apply to each Mood
Disorder (See linked section).
Table 1a. Episode specifiers that apply to Mood

Disorders
Severity/
Psy- chotic/
Remission
Chroni
c
With Catatonic
Features
Major Depressive Disorder, Single Episode

X
X
X
Major Depressive Disorder, Recurrent
X
X
X
Dysthymic Disorder
Bipolar I Disorder, Single Manic Episode

X
X
Hypomanic

Manic
X
X
Mixed
X
X
Depressed
X
X
X
Unspecified
Bipolar II Disorder, Hypomanic
Bipolar II Disorder, Depressed

X
X
X
Table 1b. Episode specifiers that apply to Mood
Disorders (cont.)
With Melancholic
Features
With Atypical
Features
With Postpartum
Onset
Major Depressive Disorder, Single

Episode
X
X
X
Major Depressive Disorder,
Recurrent
X
X
X
Dysthymic Disorder
X
Bipolar I Disorder, Single Manic

Episode
X
Bipolar I Disorder, Most Recent
Episode Hypomanic

Episode Manic
X
Episode Mixed
X
Episode Depressed
X
X
X
Episode Unspecified

X
X
X
Severity/Psychotic/Remission Specifiers for
Major
Depressive Episode
In Major Depressive Disorder, these specifiers

indicate either the severity of the current
Major Depressive Episode or the level of
remission if full criteria are no longer met. In
Bipolar I and Bipolar II Disorder, these
specifiers indicate either the severity of the
current Major Depressive Episode or the level of
remission if the most recent episode
was a Major Depressive Episode. If criteria are
currently met for the Major Depressive
Episode, it can be classified as Mild, Moderate,
Severe Without Psychotic Features, or
Severe With Psychotic Features. If the criteria
are no longer met, the specifier indicates
whether the most recent Major Depressive
Episode is in partial or full remission. For
Major Depressive Disorder and most of the
Bipolar I Disorders, the specifier is reflected
in the fifth-digit coding for the disorder.
1Mild, 2Moderate, 3Severe Without

Psychotic Features. Severity is judged
to be mild, moderate, or severe based on the
number of criteria symptoms, the severity
of the symptoms, and the degree of functional
disability and distress. Mild episodes are
characterized by the presence of only five or six
depressive symptoms and either mild
disability or the capacity to function normally
but with substantial and unusual effort.
Episodes that are Severe Without Psychotic
Features are characterized by the presence
of most of the criteria symptoms and clear-cut,

observable disability (e.g., inability to
work or care for children). Moderate episodes
have a severity that is intermediate
between mild and severe.
4Severe With Psychotic Features. This

specifier indicates the presence of either
delusions or hallucinations (typically auditory)
during the current episode. Most
commonly, the content of the delusions or
hallucinations is consistent with the
depressive themes. Such mood-congruent
psychotic features include delusions of guilt
(e.g., of being responsible for illness in a loved
one), delusions of deserved punishment
(e.g., of being punished because of a moral
transgression or some personal
inadequacy), nihilistic delusions (e.g., of world
or personal destruction), somatic
delusions (e.g., of cancer or one's body "rotting
away"), or delusions of poverty (e.g., of
being bankrupt). Hallucinations, when present,
are usually transient and not elaborate
and may involve voices that berate the person
for shortcomings or sins.
Less commonly, the content of the

hallucinations or delusions has no apparent
relationship to depressive themes. Such mood-
incongruent psychotic features include
persecutory delusions (without depressive
themes that the individual deserves to be
persecuted), delusions of thought insertion (i.e.,
one's thoughts are not one's own),
delusions of thought broadcasting (i.e., others
can hear one's thoughts), and delusions of
control (i.e., one's actions are under outside
control). These features are associated with
a poorer prognosis. The clinician can indicate
the nature of the psychotic features by
specifying With Mood-Congruent Features or
With Mood-Incongruent Features.
5In Partial Remission, 6In Full Remission.

Full Remission requires a period of
at least 2 months in which there are no
significant symptoms of depression. There are
two ways for the episode to be In Partial
Remission: 1) some symptoms of a Major
Depressive Episode are still present, but full
criteria are no longer met; or 2) there are no
longer any significant symptoms of a Major
Depressive Episode, but the period of
remission has been less than 2 months. If the
Major Depressive Episode has been
superimposed on Dysthymic Disorder, the
diagnosis of Major Depressive Disorder, In
Partial Remission, is not given once the full
criteria for a Major Depressive Episode are
no longer met; instead, the diagnosis is
Disorder, Prior History.
Criteria for Severity/Psychotic/Remission

Specifiers for
current (or most recent) Major Depressive
Episode
Note: Code in fifth digit. Mild, Moderate,

Severe Without Psychotic Features,
and Severe With Psychotic Features can be
applied only if the criteria are
currently met for a Major Depressive Episode.
In Partial Remission and In Full
Remission can be applied to the most recent
Major Depressive Episode in Major
Depressive Disorder and to a Major Depressive
Episode in Bipolar I or II
Disorder only if it is the most recent type of
mood episode.
.x1Mild: Few, if any, symptoms in excess of
those required to make the
diagnosis and symptoms result in only minor
impairment in occupational
functioning or in usual social activities or
relationships with others.
.x2Moderate: Symptoms or functional
impairment between "mild" and
"severe."
.x3Severe Without Psychotic Features:
Several symptoms in excess of those
required to make the diagnosis, and symptoms
markedly interfere with
occupational functioning or with usual social
activities or relationships with
others.
.x4Severe With Psychotic Features: Delusions
or hallucinations. If possible,
specify whether the psychotic features are
mood-congruent or mood-
incongruent:
Mood-Congruent Psychotic Features: Delusions
or hallucinations whose
content is entirely consistent with the typical
depressive themes of personal
inadequacy, guilt, disease, death, nihilism, or
deserved punishment.
Mood-Incongruent Psychotic Features:
Delusions or hallucinations whose
content does not involve typical depressive
themes of personal
inadequacy, guilt, disease, death, nihilism, or
deserved punishment.
Included are such symptoms as persecutory
delusions (not directly related
to depressive themes), thought insertion, thought
broadcasting, and
delusions of control.
.x5In Partial Remission: Symptoms of a
Major Depressive Episode are present
but full criteria are not met, or there is a period
without any significant symptoms
of a Major Depressive Episode lasting less than
2 months following the end of
the Major Depressive Episode. (If the Major

Depressive Episode was
superimposed on Dysthymic Disorder, the
diagnosis of Dysthymic Disorder
alone is given once the full criteria for a Major
Depressive Episode are no longer
met.)
.x6In Full Remission: During the past 2
months, no significant signs or
symptoms of the disturbance were present.
.x0Unspecified.

Manic
Episode
In Bipolar I Disorder, these specifiers indicate

either the severity of the current Manic
Episode or the level of remission if the most
recent episode was a Manic Episode. If
criteria are currently met for the Manic Episode,
it can be classified as Mild, Moderate,
Severe Without Psychotic Features, or Severe
With Psychotic Features. If the criteria
are no longer met for a Manic Episode, the
specifier indicates whether the most recent
Manic Episode is in partial or full remission.
These specifiers are reflected in the fifth-
digit coding for the disorder.

of the symptoms, the degree of functional
disability, and the need for supervision. Mild
episodes are characterized by the presence of
only three or four manic symptoms.
Moderate episodes are characterized by an
extreme increase in activity or impairment in
judgment. Episodes that are Severe Without
Psychotic Features are characterized by
the need for almost continual supervision to
protect the individual from harm to self or
others.
hallucinations is consistent with the manic
themes, that is, they are mood-congruent
psychotic features. For example, God's voice
may be heard explaining that the person has a
special mission. Persecutory delusions
may be based on the idea that the person is being
persecuted because of some special
relationship or attribute.

relationship to manic themes, that is, they are
mood-incongruent psychotic features.
These may include persecutory delusions (not
directly related to grandiose themes),
delusions of thought insertion (i.e., one's
thoughts are not one's own), delusions of
thought broadcasting (i.e., others can hear one's
thoughts), and delusions of control (i.e.,
one's actions are under outside control). The
presence of these features may be
associated with a poorer prognosis. The clinician

can indicate the nature of the psychotic
features by specifying With Mood-Congruent
Features or With Mood-Incongruent
Features.

significant symptoms of mania. There are two
ways for the episode to be In Partial Remission:
1) symptoms of a Manic Episode are
still present, but full criteria are no longer met;
or 2) there are no longer any significant
symptoms of a Manic Episode, but the period of
remission has been less than 2 months.
Specifiers for
current (or most recent) Manic Episode

currently met for a Manic Episode. In Partial
Remission and In Full Remission
can be applied to a Manic Episode in Bipolar I
Disorder only if it is the most
recent type of mood episode.
.x1Mild: Minimum symptom criteria are met
for a Manic Episode.
.x2Moderate: Extreme increase in activity or
impairment in judgment.
Almost continual supervision required
to prevent physical harm to self or others.
incongruent:
manic themes of inflated
worth, power, knowledge, identity, or special
relationship to a deity or
famous person.
content does not involve typical manic themes of
inflated worth, power,
knowledge, identity, or special relationship to a
deity or famous person.
Included are such symptoms as persecutory
delusions (not directly related
to grandiose ideas or themes), thought insertion,
and delusions of being
controlled.
Manic Episode are present but full
criteria are not met, or there is a period without
any significant symptoms of a
Manic Episode lasting less than 2 months
following the end of the Manic
Episode.
months no significant signs or
.x0Unspecified.

Mixed
Episode
In Bipolar I Disorder, these specifiers indicate

either the severity of the current Mixed
Episode or the level of remission if the most
recent episode was a Mixed Episode. If
criteria are currently met for the Mixed Episode,
it can be classified as Mild, Moderate,
Severe Without Psychotic Features, or Severe
With Psychotic Features. If the criteria
are no longer met for a Mixed Episode, the
specifier indicates whether the most recent
Mixed Episode is in partial or full remission.
These specifiers are reflected in the fifth-
digit coding for the disorder.

of the symptoms, the degree of functional
disability, and the need for supervision. Mild
episodes are characterized by the presence of
only three or four manic symptoms and
five or six depressive symptoms. Moderate
episodes are characterized by an extreme
increase in activity or impairment in judgment.
Episodes that are Severe Without
Psychotic Features are characterized by the need
for almost continual supervision to
protect the individual from harm to self or
others.

hallucinations is consistent with either the
manic or depressive themes, that is, they are
mood-congruent psychotic features. For
example, God's voice may be heard explaining
that the person has a special mission.
Persecutory delusions may be based on the idea
that the person is being persecuted
because of being especially deserving of
punishment or having some special
relationship or attribute.
relationship to either manic or depressive
themes, that is, they are mood-incongruent
psychotic features. These may include delusions
of thought insertion (i.e., one's thoughts
are not one's own), delusions of thought
broadcasting (i.e., others can hear one's
thoughts), and delusions of control (i.e., one's

actions are under outside control). These
features are associated with a poorer prognosis.
The clinician can indicate the nature of
the psychotic features by specifying With Mood-
Congruent Features or With Mood-
Incongruent Features.

significant symptoms of mania or depression.
There are two ways for the episode to be In
Partial Remission: 1) symptoms of a Mixed
Episode are still present, but full criteria are no
longer met; or 2) there are no longer any
significant symptoms of a Mixed Episode, but
the period of remission has been less than
2 months.

Specifiers for
current (or most recent) Mixed Episode

currently met for a Mixed Episode. In Partial
Remission and In Full Remission
can be applied to a Mixed Episode in Bipolar I
recent type of mood episode.
.x1Mild: No more than minimum symptom
criteria are met for both a Manic
Episode and a Major Depressive Episode.
.x2Moderate: Symptoms or functional
impairment between "mild" and
"severe."
Almost continual supervision required
to prevent physical harm to self or others.
incongruent:
manic or depressive themes.
content does not involve typical manic or
depressive themes. Included are
such symptoms as persecutory delusions (not
directly related to grandiose
or depressive themes), thought insertion, and
delusions of being controlled.
Mixed Episode are present but full
criteria are not met, or there is a period without
any significant symptoms of a
Mixed Episode lasting less than 2 months
following the end of the Mixed
Episode.
months, no significant signs or
.x0Unspecified.
Chronic Specifier for a Major Depressive

Episode
This specifier indicates the chronic nature of a
Major Depressive Episode (i.e., that full
criteria for a Major Depressive Episode have
been continuously met for at least 2 years).
This specifier applies to the current (or, if the
full criteria are not currently met for a Major
Depressive Episode, to the most recent) Major
Depressive Episode in Major Depressive
Disorder and to the current (or most recent)
Major Depressive Episode in Bipolar I or
Bipolar II Disorder only if it is the most recent
type of mood episode.
Criteria for Chronic Specifier
Specify if:
Chronic (can be applied to the current or most
recent Major Depressive
Episode in Major Depressive Disorder and to a
in Bipolar I or II Disorder only if it is the most
recent type of mood episode)
Full criteria for a Major Depressive Episode
have been met continuously for
at least the past 2 years.
Catatonic Features Specifier
The specifier With Catatonic Features can be

applied to the current Major Depressive,
Manic, or Mixed Episode in Major Depressive
Disorder, Bipolar I Disorder, or Bipolar II
Disorder. If full criteria are no longer met for a
mood episode, the specifier applies to the
most recent mood episode. The specifier With
Catatonic Features is appropriate when
the clinical picture is characterized by marked
psychomotor disturbance that may involve
motoric immobility, excessive motor activity,
extreme negativism, mutism, peculiarities of
voluntary movement, echolalia, or echopraxia.
Motoric immobility may be manifested by
catalepsy (waxy flexibility) or stupor. The
excessive motor activity is apparently
purposeless and is not influenced by external
stimuli. There may be extreme negativism
that is manifested by the maintenance of a rigid
posture against attempts to be moved or
resistance to all instructions. Peculiarities of
voluntary movement are manifested by the
assumption of inappropriate or bizarre postures
or by prominent grimacing. Echolalia
(the pathological, parrotlike, and apparently
senseless repetition of a word or phrase just
spoken by another person) and echopraxia (the
repetitive imitation of the movements of
another person) are often present. Additional
features may include stereotypies,
mannerisms, and automatic obedience or
mimicry. During severe catatonic stupor or
excitement, the person may need careful
supervision to avoid self-harm or harm to
others. Potential consequences include
malnutrition, exhaustion, hyperpyrexia, or self-
inflicted injury.
Catatonic states have been found to occur in

5%9% of inpatients. Among inpatients
with catatonia, 25%50% of cases occur in
association with Mood Disorders, 10%15%
of cases occur in association with Schizophrenia
(see Schizophrenia, Catatonic Type,
See linked section), and the remainder occur in
association with other mental disorders
(e.g., Obsessive-Compulsive Disorder,
Personality Disorders, and Dissociative
Disorders). It is important to note that catatonia
can also occur in a wide variety of
general medical conditions including, but not
limited to, those due to infectious,
metabolic, neurological conditions (see
Catatonic Disorder Due to a General Medical
Condition, See linked section), or can be due to
a side effect of a medication (e.g., a
Medication-Induced Movement Disorder, See
linked section). Because of the
seriousness of the complications, particular
attention should be paid to the possibility
that the catatonia is due to Neuroleptic
Malignant Syndrome (See linked section).
Criteria for Catatonic Features Specifier
Specify if:
With Catatonic Features (can be applied to the
current or most recent Major
Depressive Episode, Manic Episode, or Mixed
Episode in Major Depressive
Disorder, Bipolar I Disorder, or Bipolar II
Disorder)
The clinical picture is dominated by at least two
of the following:
1. motoric immobility as evidenced by catalepsy
(including waxy
flexibility) or stupor
2. excessive motor activity (that is apparently
purposeless and not
influenced by external stimuli)
3. extreme negativism (an apparently motiveless
resistance to all
instructions or maintenance of a rigid posture
against attempts to be
moved) or mutism
4. peculiarities of voluntary movement as
evidenced by posturing
(voluntary assumption of inappropriate or
bizarre postures),
stereotyped movements, prominent mannerisms,
or prominent
grimacing
5. echolalia or echopraxia
Melancholic Features Specifier
The specifier With Melancholic Features can be

applied to the current (or, if the full
criteria are not currently met for a Major
Depressive Episode, to the most recent) Major
Major Depressive Episode in Bipolar I or II
Disorder only if it is the most recent type of
mood episode. The essential feature of a Major
Depressive Episode, With Melancholic
Features, is loss of interest or pleasure in all, or
almost all, activities or a lack of reactivity
to usually pleasurable stimuli. The individual's
depressed mood does not improve, even
temporarily, when something good happens
(Criterion A). In addition, at least three of the
following symptoms are present: a distinct
quality of the depressed mood, depression
that is regularly worse in the morning, early
morning awakening, psychomotor retardation
or agitation, significant anorexia or weight loss,
or excessive or inappropriate guilt
(Criterion B).
The specifier With Melancholic Features is

applied if these features are present at the
nadir 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
for very desired events, the depressed mood
does not brighten at all or brightens only
partially (e.g., up to 20%40% of normal for
only minutes at a time). The distinct quality
of mood that is characteristic of the With
Melancholic Features specifier is experienced
by individuals as qualitatively different from the
sadness experienced during
bereavement or a nonmelancholic depressive
episode. This may be elicited by asking
the person to compare the quality of the current
depressed mood with the mood
experienced after the death of a loved one. A
depressed mood that is described as
merely more severe, longer-lasting, or present
without a reason is not considered distinct
in quality. Psychomotor changes are nearly
always present and are observable by
others. Individuals with melancholic features are
less likely to have a premorbid
Personality Disorder, to have a clear precipitant
to the episode, and to respond to a trial
of placebo medication. One consequence of a
lower probability of response to placebo is
a greater need for active antidepressant
treatment.
These features exhibit only a modest tendency to

repeat across episodes in the same
individual. They are more frequent in inpatients,
as opposed to outpatients, and are less
likely to occur in milder than in more severe
Major Depressive Episodes and are more
likely to occur in those with psychotic features.

Melancholic features are more frequently
associated with laboratory findings of
dexamethasone nonsuppression; elevated
cortisol
concentrations in plasma, urine, and saliva;
alterations of sleep EEG profiles; abnormal
tyramine challenge test; and an abnormal
asymmetry on dichotic listening tasks.
Criteria for Melancholic Features Specifier
Specify if:
With Melancholic Features (can be applied to
the current or most recent
Major Depressive Episode in Major Depressive
Disorder and to a Major
Depressive Episode in Bipolar I or Bipolar II
recent type of mood episode)
A. Either of the following, occurring during the
most severe period of the current
episode:
1. loss of pleasure in all, or almost all, activities
2. lack of reactivity to usually pleasurable
stimuli (does not feel much better,
even temporarily, when something good
happens)
B. Three (or more) of the following:
1. distinct quality of depressed mood (i.e., the
depressed mood is
experienced as distinctly different from the kind
of feeling experienced after
the death of a loved one)
2. depression regularly worse in the morning
3. early morning awakening (at least 2 hours
before usual time of
awakening)
4. marked psychomotor retardation or agitation
5. significant anorexia or weight loss
6. excessive or inappropriate guilt
Atypical Features Specifier
The specifier With Atypical Features can be

applied to the current (or, if the full criteria
are not currently met for a Major Depressive
Episode, to the most recent) Major
Major Depressive Episode in Bipolar I or
Bipolar II Disorder only if it is the most recent
type of mood episode, or to Dysthymic Disorder.
"Atypical depression" has historical
significance (i.e., atypical in contradistinction to
the more classical "endogenous"
presentations of depression) and does not
connote an uncommon or unusual clinical
presentation as the term might imply. The
essential features are mood reactivity
(Criterion A) and the presence of at least two of
the following features (Criterion B):
increased appetite or weight gain, hypersomnia,
leaden paralysis, and a long-standing
pattern of extreme sensitivity to perceived
interpersonal rejection. These features
predominate during the most recent 2-week
period (or the most recent 2-year period for
Dysthymic Disorder). The specifier With
Atypical Features is not given if the criteria for
With Melancholic Features or With Catatonic
Features have been met during the same
Major Depressive Episode. When used to
describe the most recent Major Depressive
Episode (as opposed to a current episode), the
specifier applies if the features
predominate during any 2-week period.
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
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
interpersonal 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. The problems that result from rejection
sensitivity must be significant enough to
result in functional impairment. There may be
stormy relationships with frequent
disruptions and an inability to sustain a longer-
lasting relationship. The individual's
reaction to rebuff or criticism may be manifested

by leaving work early, using substances
excessively, or displaying other clinically
significant maladaptive behavioral responses.
There may also be avoidance of relationships
due to the fear of interpersonal rejection.
Being occasionally touchy or overemotional
does not qualify as a manifestation of
interpersonal rejection sensitivity. Personality
Disorders (e.g., Avoidant Personality
Disorder) and Anxiety Disorders (e.g.,
Separation Anxiety Disorder, Specific Phobia, or
Social Phobia) may be more common in those
with atypical features. The laboratory
findings associated with a Major Depressive
Episode With Melancholic Features are
generally not present in association with an
episode with atypical features.
Atypical features are two to three times more

common in women. Individuals with
atypical features report an earlier age at onset of
their depressive episodes (e.g., while in
high school) and frequently have a more
chronic, less episodic course, with only partial
interepisode recovery. Younger individuals may
be more likely to have episodes with
atypical features, whereas older individuals may
more often have episodes with
melancholic features. Episodes with atypical
features are more common in Bipolar I
Disorder, Bipolar II Disorder, and in Major
Depressive Disorder, Recurrent, occurring in a
seasonal pattern. Depressive episodes with
Atypical Features are more likely to respond
to treatment with monoamine oxidase inhibitors
than with tricyclic antidepressants. The
predictive value of Atypical Features is less
clear with newer treatments, such as
selective serotonin reuptake inhibitors or
interpersonal or cognitive psychotherapies.
Criteria for Atypical Features Specifier
Specify if:
With Atypical Features (can be applied when
these features predominate
during the most recent 2 weeks of a current
Major Depressive Episode in
Major Depressive Disorder or in Bipolar I or
Bipolar II Disorder when a
current Major Depressive Episode is the most
recent type of mood episode,
or when these features predominate during the
most recent 2 years of
Dysthymic Disorder; if the Major Depressive
Episode is not current, it
applies if the feature predominates during any 2-
week period)
A. Mood reactivity (i.e., mood brightens in
response to actual or potential
positive events)
B. Two (or more) of the following features:
1. significant weight gain or increase in appetite
2. hypersomnia
3. leaden paralysis (i.e., heavy, leaden feelings
in arms or legs)
4. long-standing pattern of interpersonal
rejection sensitivity (not limited to
episodes of mood disturbance) that results in
significant social or
occupational impairment
C. Criteria are not met for With Melancholic
Features or With Catatonic Features
during the same episode.
Postpartum Onset Specifier
The specifier With Postpartum Onset can be

applied to the current (or, if the full criteria
are not currently met for a Major Depressive,
Manic, or Mixed Episode, to the most
recent) Major Depressive, Manic, or Mixed
Episode of Major Depressive Disorder,
Bipolar I Disorder, or Bipolar II Disorder or to
Brief Psychotic Disorder (See linked
section) if onset is within 4 weeks after
childbirth. The symptoms of the postpartum-
onset
Major Depressive, Manic, or Mixed Episode do
not differ from the symptoms in
nonpostpartum mood episodes. Symptoms that
are common in postpartum-onset
episodes, though not specific to postpartum
onset, include fluctuations in mood, mood
lability, and preoccupation with infant well-
being, the intensity of which may range from
overconcern to frank delusions. The presence of
severe ruminations or delusional
thoughts about the infant is associated with a
significantly increased risk of harm to the
infant.
Postpartum-onset mood episodes can present

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 it can also occur in severe
postpartum mood episodes without such
specific delusions or hallucinations. Postpartum
mood (Major Depressive, Manic, or
Mixed) 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 Mood
Disorder (especially Bipolar I Disorder). Once a
woman has had a postpartum episode
with psychotic features, the risk of recurrence
with each subsequent delivery is between
30% and 50%. There is also some evidence of
increased risk of postpartum psychotic
mood episodes among women without a history
of Mood Disorders with a family history
of Bipolar Disorders. Postpartum episodes must
be differentiated from delirium occurring
in the postpartum period, which is distinguished
by a decreased level of awareness or
attention.
Women with postpartum Major Depressive

Episodes often have severe anxiety and
even Panic Attacks. Maternal attitudes toward
the infant are highly variable but can
include disinterest, fearfulness of being alone
with the infant, or overintrusiveness that
inhibits adequate infant rest. It is important to
distinguish postpartum mood episodes
from the "baby blues," which affect up to 70%
of women during the 10 days postpartum,
are transient, and do not impair functioning.
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.
A past personal history of
nonpostpartum Mood Disorder and a family
history of Mood Disorders also increase the
risk for the development of a postpartum Mood
Disorder. The risk factors, recurrence
rates, and symptoms of postpartum-onset Mood
Episodes are similar to those of
nonpostpartum Mood Episodes. However, the
postpartum period is unique with respect
to the degree of neuroendocrine alterations and
psychosocial adjustments, the potential
impact of breast-feeding on treatment planning,
and the long-term implications of a
history of postpartum Mood Disorder on
subsequent family planning.
Criteria for Postpartum Onset Specifier
Specify if:
With Postpartum Onset (can be applied to the
current or most recent Major
Depressive, Manic, or Mixed Episode in Major
Depressive Disorder, Bipolar
I Disorder, or Bipolar II Disorder; or to Brief
Psychotic Disorder)
Onset of episode within 4 weeks postpartum
Specifiers Describing Course of Recurrent

Episodes
A number of specifiers for Mood Disorders are
provided to increase diagnostic specificity
and create more homogeneous subgroups, assist
in treatment selection, and improve
the prediction of prognosis. Specifiers that
describe the course of recurrent episodes
include Longitudinal Course Specifiers (With or
Without Full Interepisode Recovery),
Seasonal Pattern, and Rapid Cycling. These
specifiers cannot be coded. Table 2
indicates which course specifiers apply to each
Mood Disorder.
Table 2. Course specifiers that apply to Mood

Disorders
With/ Without Inter-episode

Recovery
Seasonal
Pattern
Rapid
Cycling
Major Depressive Disorder, Single

Episode
Major Depressive Disorder, Recurrent

X
X
Dysthymic Disorder
Bipolar I Disorder, Single Manic

Episode
Episode Hypomanic
X
X
X
Episode Manic
X
X
X
Episode Mixed
X
X
X
Episode Depressed
X
X
X
Episode Unspecified
X
X
X
X
X
X
X
X
X
Longitudinal Course Specifiers (With or

Without Full
Interepisode Recovery)
The specifiers With Full Interepisode Recovery
and Without Full Interepisode Recovery
are provided to help characterize the course of
illness in individuals with Recurrent Major
Depressive Disorder, Bipolar I Disorder, or
Bipolar II Disorder. These specifiers should
be applied to the period of time between the two
most recent episodes. The
characterization of course is further enhanced by
noting the presence of antecedent
Dysthymic Disorder.
The four graphs below depict prototypical

courses. A shows the course of Major
Depressive Disorder, Recurrent, in which there
is no antecedent Dysthymic Disorder and
there is a period of full remission between the
episodes. This course pattern predicts the
best future prognosis. B shows the course of
Major Depressive Disorder, Recurrent, in
which there is no antecedent Dysthymic
Disorder but in which prominent symptoms
persist between the two most recent
episodesthat is, no more than partial remission
is
attained. C shows the rare pattern (present in
fewer than 3% of individuals with Major
Depressive Disorder) of Major Depressive
Disorder, Recurrent, with antecedent
Dysthymic Disorder but with full interepisode
recovery between the two most recent
episodes. D shows the course of Major
Depressive Disorder, Recurrent, in which there
is
antecedent Dysthymic Disorder and in which
there is no period of full remission between
the two most recent episodes. This pattern,
commonly referred to as "double depression"
(See linked section), is seen in about 20%25%
Disorder.
In general, individuals with a history of Without
Full Interepisode Recovery have a
persistence of that pattern between subsequent
episodes. They also appear more likely
to have more Major Depressive Episodes than
those with full interepisode recovery.
Dysthymic Disorder prior to the first episode of
Major Depressive Disorder is most likely
to be associated with lack of full interepisode
recovery subsequently. These specifiers
may also be applied to the period of time
between the most recent mood episodes in
Bipolar I Disorder or Bipolar II Disorder to
indicate presence or absence of mood
symptoms.
Figure 9-1.
Criteria for Longitudinal Course Specifiers
Specify if (can be applied to Recurrent Major

Depressive Disorder or Bipolar I or II
Disorder):
With Full Interepisode Recovery: if full
remission is attained between the
two most recent Mood Episodes
Without Full Interepisode Recovery: if full
remission is not attained between
the two most recent Mood Episodes
Seasonal Pattern Specifier
The specifier With Seasonal Pattern can be

applied to the pattern of Major Depressive
Episodes in Bipolar I Disorder, Bipolar II
Disorder, or Major Depressive Disorder,
Recurrent. The essential feature is the onset and
remission of Major Depressive
Episodes at characteristic 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
episodes. This pattern of onset and remission of
episodes must have occurred during the
last 2 years, without any nonseasonal episodes
occurring during this period. In addition,
the seasonal depressive episodes must
substantially outnumber any nonseasonal
depressive episodes over the individual's
lifetime. This specifier does not apply to those
situations in which the pattern is better explained
by seasonally linked psychosocial
stressors (e.g., seasonal unemployment or school
schedule). Major Depressive
Episodes that occur in a seasonal pattern are
often characterized by prominent anergy,
hypersomnia, overeating, weight gain, and a
craving for carbohydrates. It is unclear
whether a seasonal pattern is more likely in
Major Depressive Disorder, Recurrent, 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. Bright visible-spectrum light used in
treatment may be associated with switches
into Manic or Hypomanic Episodes.
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 predictor of
seasonality, with younger persons at higher risk
for winter depressive episodes. Women
comprise 60%90% of persons with seasonal
pattern, but it is unclear whether female
gender is a specific risk factor over and above
the risk associated with recurrent Major
Depressive Disorder. Although this specifier
applies to seasonal occurrence of full Major
Depressive Episodes, some research suggests
that a seasonal pattern may also
describe the presentation in some individuals
with recurrent winter depressive episodes
that do not meet criteria for a Major Depressive
Episode.
Criteria for Seasonal Pattern Specifier
Specify if:
With Seasonal Pattern (can be applied to the
Episodes in Bipolar I Disorder, Bipolar II
Disorder, or Major Depressive
Disorder, Recurrent)
A. There has been a regular temporal
relationship between the onset of
Major Depressive Episodes in Bipolar I or
Bipolar II Disorder or Major
Depressive Disorder, Recurrent, and a particular
time of the year (e.g.,
regular appearance of the Major Depressive
Episode in the fall or winter).
Note: Do not include cases in which there is an
obvious effect of
seasonal-related psychosocial stressors (e.g.,
regularly being
unemployed every winter).
B. Full remissions (or a change from depression
to mania or hypomania)
also occur at a characteristic time of the year
(e.g., depression disappears
in the spring).
C. In the last 2 years, two Major Depressive
Episodes have occurred that
demonstrate the temporal seasonal relationships
defined in Criteria A and
B, and no nonseasonal Major Depressive
Episodes have occurred during
that same period.
D. Seasonal Major Depressive Episodes (as
described above) substantially
outnumber the nonseasonal Major Depressive
Episodes that may have
occurred over the individual's lifetime.
Rapid-Cycling Specifier
The specifier With Rapid Cycling can be applied

to Bipolar I Disorder or Bipolar II
Disorder. The essential feature of a rapid-cycling
Bipolar Disorder is the occurrence of
four or more mood episodes during the previous
12 months. These episodes can occur
in any combination and order. The episodes
must meet both the duration and symptom
criteria for a Major Depressive, Manic, Mixed,
or Hypomanic Episode and must be
demarcated by either a period of full remission
or by a switch to an episode of the
opposite polarity. Manic, Hypomanic, and
Mixed Episodes are counted as being on the
same pole (e.g., a Manic Episode immediately
followed by a Mixed Episode counts as
only one episode in considering the specifier
With Rapid Cycling). 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, corticosteroids) or a
general medical condition.
Rapid cycling occurs in approximately

10%20% of individuals with Bipolar Disorder
seen in Mood Disorders clinics. Whereas in
Bipolar Disorder in general the sex ratio is
equal, women comprise 70%90% of
individuals with a rapid-cycling pattern. The
mood
episodes are not linked to any phase of the
menstrual cycle and occur in both pre- and
postmenopausal women. Rapid cycling may be
associated with hypothyroidism, certain
neurological conditions (e.g., multiple sclerosis),
Mental Retardation, head injury, or
antidepressant treatment. Rapid cycling can
occur at any time during the course of
Bipolar Disorder and may appear and disappear,
particularly if it is associated with
antidepressant use. There is some evidence that
some individuals with rapid cycling
have an acceleration of their cycling rate after
exposure to antidepressant medication.
The development of rapid cycling is associated
with a poorer longer-term prognosis.
Criteria for Rapid-Cycling Specifier
Specify if:
With Rapid Cycling (can be applied to Bipolar I
Disorder or Bipolar II
Disorder)
At least four episodes of a mood disturbance in
the previous 12 months
that meet criteria for a Major Depressive, Manic,
Mixed, or Hypomanic
Episode.
Note: Episodes are demarcated either by partial
or full remission for at least
2 months or a switch to an episode of opposite
polarity (e.g., Major
Depressive Episode to Manic Episode).

Mood Disorders Old

Uploaded by

Copyright:

Available Formats

Mood Disorders Old

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Mood Disorders Old

Uploaded by

Copyright:

Available Formats

Mood Disorders

The Mood Disorders section includes disorders

The Mood Disorders are divided into

o Major Depressive Disorder is characterized

o Dysthymic Disorder is characterized by at

 Bipolar I Disorder is characterized by one or

 Bipolar II Disorder is characterized by one

 Bipolar Disorder Not Otherwise Specified is

 Mood Disorder Due to a General Medical

 Mood Disorder Not Otherwise Specified is

The specifiers described in the third part of the

Mild, Moderate, Severe Without Psychotic

Recording Procedures for Major Depressive

Selecting diagnostic codes. The diagnostic

For Bipolar I Disorder:

Recording the name of the diagnosis. In

2. Specifiers coded in the fourth digit (e.g.,

3. Specifiers coded in the fifth digit (e.g., Mild,

4. As many specifiers (without codes) as apply

5. As many specifiers (without codes) as apply

The following examples illustrate how to record

· 296.32 Major Depressive Disorder,

Major Depressive Episode

The essential feature of a Major Depressive

The mood in a Major Depressive Episode is

individuals who complain of feeling "blah,"

Loss of interest or pleasure is nearly always

The most common sleep disturbance associated

Psychomotor changes include agitation (e.g., the

Decreased energy, tiredness, and fatigue are

The sense of worthlessness or guilt associated

Many individuals report impaired ability to

Frequently there may be thoughts of death,

others so that they can accomplish the suicide.

A diagnosis of a Major Depressive Episode is

The degree of impairment associated with a

A careful interview is essential to elicit

By definition, a Major Depressive Episode is not

Associated Features and Disorders

Associated descriptive features and mental

Sleep EEG abnormalities may be evident in

The pathophysiology of a Major Depressive

Specific Culture, Age, and Gender Features

Culture can influence the experience and

The core symptoms of a Major Depressive

Women are at significantly greater risk than men

Symptoms of a Major Depressive Episode

A Major Depressive Episode must be

A Substance-Induced Mood Disorder is

In elderly persons, it is often difficult to

Major Depressive Episodes with prominent

Distractibility and low frustration tolerance can

A Major Depressive Episode that occurs in

include marked functional impairment, morbid

Finally, periods of sadness are inherent aspects

Criteria for Major Depressive Episode

A. Five (or more) of the following symptoms

A Manic Episode is defined by a distinct period

The elevated mood of a Manic Episode may be

wishes are thwarted. Lability of mood (e.g., the