Mood Disorders and Self-Harm

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Mood Disorders and Self-Harm A significant change in the DSM-5 was to separate the bipolar disorders from the depressive disorders. These two new classifications— formerly combined in the DSM-IV under “Mood Disorders”— represent a shift to enhanced understanding of the differences between these groups, despite some common criteria. In addition, the DSM-5 includes suicidal behavior disorder, nonsuicidal self-injury, and persistent complex bereavement disorder under the chapter “Conditions for Further Study.” These are not recognized as clinical disorders (for purpose of diagnosis) at this time; however, the specific descriptions provided can enhance clinicians’ understanding of these presentations and provide guidance for treatment. Below is a brief overview of significant changes to the diagnostic criteria and classifications.

Bipolar and Related Disorders As noted above, this is a new classification in the DSM-5 and is placed between the schizophrenia spectrum and depressive disorders to help represent its presence along the continuum of diagnostic criteria. Bipolar and related disorders includes bipolar I disorder; bipolar II disorder; cyclothymic disorder; substance/medication induced bipolar and related disorder; bipolar and related disorder due to another medical condition; other specified bipolar and related disorder; and unspecified bipolar disorder and related disorder. This group includes several new or revised diagnoses. Changes to Criterion A for both manic and hypomanic episodes now includes and emphasis on change to activity or energy. In addition, the diagnosis of “bipolar I, mixed episode” has been removed. Specifiers for all bipolar disorders are described together and provide for specific presenting characteristics related to the diagnoses. The DSM-5 also includes explanations for using these specifiers, their clinical significance, and suggested treatment approaches. In an attempt to more accurately diagnose this group of disorders, these represent considerable expansion from the DSM-IV specifiers. A new specifier “with anxious distress” was added to both the bipolar and depressive classifications to more expressly identify anxiety symptoms not part of the diagnostic criteria of bipolar or depressive disorders, yet commonly observed in both of these classifications. The diagnosis bipolar disorder not otherwise specified has been removed, and two new diagnoses added: other specified bipolar and related disorder and unspecified bipolar disorder and related disorder. Both of these diagnoses represent significant clinical distress or impairment based on bipolar diagnostic criteria but do not meet full criteria for a specific bipolar class diagnosis. Clinicians should use other specified bipolar and related disorder with the specific reason for the more general diagnosis (e.g., short duration manic or hypomanic episode). The latter diagnosis—unspecified bipolar disorder and related disorder—is used when clinicians cannot (or choose not to) identify reasons for the inability to make a more specific diagnosis, yet clearly observe multiple criteria from the bipolar and related disorders classification.

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Depressive Disorders This is a new classification, separated from the more general class of mood disorders in the DSM-IV. Several depressive diagnoses were added to the DSM-5, including one specific to children. In addition, there have been several revisions to existing diagnoses in an attempt to make the diagnostic process more clear and reliable. As with the bipolar and related disorders, specifiers for all depressive disorders are described together and provide for specific presenting characteristics related to the diagnoses. Many of these specifiers are identical to those found in the bipolar classification; however, the clinical significance and treatment considerations discussed vary. Included in the discussion of clinical significance for specifiers is relation to suicide risk, potential precursors to other mood-related diagnoses, and suggestions for additional differential diagnoses. The diagnosis depressive disorder not otherwise specified has been removed, and two new diagnoses added: other specified depressive disorder and unspecified depressive disorder. Both of these diagnoses represent significant clinical distress or impairment based on depressive diagnostic criteria but do not meet full criteria for a specific depressive disorder diagnosis. Clinicians should use other specified depressive disorder and add the specific reason for the more general diagnosis (e.g., short duration, insufficient symptoms). The latter diagnosis—unspecified depressive disorder—is used when clinicians cannot (or choose not to) identify reasons for the inability to make a more specific diagnosis, yet clearly observe multiple criteria from the bipolar and related disorders classification. Disruptive Mood Dysregulation Disorder For this new diagnosis, partial intent was to minimize the misdiagnosis of bipolar disorder in children. It is important to note that this disorder is included in the depressive disorder classification rather than the bipolar disorder classification—this is largely due to the research supporting stronger correlations between this symptomology in youth and the development of depressive (or anxious) disorders in adolescence and adulthood. This diagnosis is characterized by persistent and recurrent outbursts of temper significantly incongruent with circumstance and present in at least two settings (e.g., home and school). The diagnosis cannot be made before age 6 nor after age 18, and the initial age of onset must be before age 10. The diagnosis cannot be comorbid with bipolar disorder, intermittent explosive disorder, or oppositional defiant disorder. In addition, the observed symptomology cannot be due to substance effects nor to general medical or neurological condition. Persistent Depressive Disorder This new diagnosis is a combination both chronic major depressive disorder and dysthymic disorder from the DSM-IV. It was determined that there were few significant differences between these two diagnoses; specifiers are now used to identify features, onset, and severity. Major Depressive Disorder The most significant change to the diagnostic criteria for major depressive episode is the removal of the “bereavement exclusion.” In the DSM-IV, a required criterion to meet this diagnosis

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included that the observed symptoms were not better explained by bereavement. This has been removed in the DSM-5, with emphasis given to clinical judgment to differentiate these. Further, the DSM-5 notes the considerable variations in symptom presentation as influenced by individual history and culture as well as guidance for differential diagnosis between bereavement and major depressive disorder. It is of note that bereavement has previously been considered a condition or state of mind rather than a disorder. However, in the DSM-5, “persistent complex bereavement” has been described in the “Conditions for Further Study” (see section below). Premenstrual Dysphoric Disorder This new diagnosis is included in the depressive disorders classification and is characterized by mood lability, anxiety, dysphoria, and irritability, and well as physiological changes. The pattern of occurrence is cyclical and associated with menstrual cycle. The diagnosis includes significant interference with normal daily functioning and observed symptoms that are not merely an exacerbation of already existing diagnoses.

Conditions for Further Study

This section of the DSM–5 includes a number of “conditions” not yet recognized as clinical disorders for diagnostic and classification purposes. However, these conditions are recognized for the patterns in presenting characteristics – thus, improved understanding of these can enhance clinicians’ treatment planning and facilitate future research. Persistent Complex Bereavement Disorder This disorder is marked by the persistence of sorrow; preoccupation with a deceased loved one; reactive distress associated with the death; and social or identity disruption. In adults, the loss must have occurred at least 12 months prior to diagnosis; in children, the loss must have occurred at least 6 months prior. There must also be significant impact on functioning, and the expression of symptoms must be inconsistent with cultural norms. The disorder can occur at any age after 1 year. Expression of symptomology may begin shortly after the loss or be delayed by months or years. In children, the impact of loss can be highly traumatic, and may be expressed differently than in adults. Complex bereavement in children may be expressed through play, regressive behaviors, and/or intense separation distress. Risk for comorbid depression rises in children and adolescents. Suicidal Behavior Disorder The key feature of this disorder is the existence of a suicide attempt within the last 24 months. If an attempt was made in the last 12–24 months, the disorder may be considered “in early remission.” The behaviors do not include self-injury for the purpose of emotional release nor simply suicidal ideation (as can be common with disorders of affect). The diagnosis can be comorbid with many other disorders; it rarely exists alone. The disorder can occur at any age but is generally absent in children under the age of 5 years.

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Nonsuicidal Self-Injury The key feature of this diagnosis is the persistent physical harm to oneself without the intention of death. Purpose of this behavior may be to diminish undesirable emotions; it may also be a form of self-punishment. The behavior tends to become increasingly frequent, with individuals often reporting a “craving” for the behavior; the behavioral expression may ultimately resemble addiction. Onset of nonsuicidal self-injurious behavior generally occurs during adolescence, and impairment or distress caused by the behaviors must be significant. However, as many individuals who participate in this behavior do not seek treatment, age of onset and severity of impairment may be difficult to reliably determine. Reference:

• American Psychiatric Association (2013). Highlights of changes from DSM-IV-TR to DSM-5. Retrieved from http://www.dsm5.org/Documents/changes%20from%20dsm-iv- tr%20to%20dsm-5.pdf

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