Psychological Disorders: Bipolar Disorder
American
Description
Bipolar I Disorder, Single Manic Episode
Presence of only one Manic Episode 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.
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 Otherwise Specified.
Bipolar
I Disorder, Most Recent Episode Hypomanic
Currently (or most recently) in a Hypomanic Episode.
There has previously been at least one Manic Episode or Mixed Episode.
The mood symptoms cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
The mood episodes in Criteria A and B are not better accounted for
by Schizoaffective Disorder and is not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
Not Otherwise Specified.
Bipolar
I Disorder, Most Recent Episode Manic
Currently (or most recently) in a Manic Episode.
There has previously been at least one Major Depressive Episode, Manic
Episode, or Mixed Episode.
The mood episodes in Criteria A and B are not better accounted for
by Schizoaffective Disorder and is not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
Not Otherwise Specified.
Bipolar
I Disorder, Most Recent Episode Mixed
Currently (or most recently) in a Mixed Episode.
There has previously been at least one Major Depressive Episode, Manic
Episode, or Mixed Episode.
The mood episodes in Criteria A and B are not better accounted for
by Schizoaffective Disorder and is not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
Not Otherwise Specified.
Bipolar
I Disorder, Most Recent Episode Depressed
Currently (or most recently) in a Major Depressive Episode.
There has previously been at least one Manic Episode or Mixed Episode.
The mood episodes in Criteria A and B are not better accounted for
by Schizoaffective Disorder and is not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
Not Otherwise Specified.
Bipolar
I Disorder, Most Recent Episode Unspecified
Criteria, except for duration, are currently (or most recently) met
for a Manic, a Hypomanic, a Mixed, or a Major Depressive Episode.
There has previously been at least one Manic Episode or Mixed Episode.
The mood symptoms cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
The mood episodes in Criteria A and B are not better accounted for
by Schizoaffective Disorder and is not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
Not Otherwise Specified.
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).
Criteria
For Mood Episodes
Major
Depressive Episode
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.
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.
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)
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.
insomnia or hypersomnia nearly every day
psychomotor agitation or retardation nearly every day (observable
by others, not merely subjective feelings of restlessness or being
slowed down)
fatigue or loss of energy nearly every day
feelings of worthlessness or excessive or inappropriate guilt (which
may be delusional) nearly every day (not merely self-reproach or guilt
about being sick)
diminished ability to think or concentrate, or indecisiveness, nearly
every day (either by subjective account or as observed by others)
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
The symptoms do not meet criteria for a Mixed Episode
The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
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).
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
A distinct period of abnormally and persistently elevated, expansive,
or irritable mood, lasting at least 1 week (or any duration if hospitalization
is necessary).
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:
inflated self-esteem or grandiosity
decreased need for sleep (e.g., feels rested after only 3 hours of
sleep)
more talkative than usual or pressure to keep talking
flight of ideas or subjective experience that thoughts are racing
distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli)
increase in goal-directed activity (either socially, at work or school,
or sexually) or psychomotor agitation
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)
The symptoms do not meet criteria for a Mixed Episode
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.
The symptoms 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).
Mixed
Episode
The criteria are met both for a Manic Episode and for a Major Depressive
Episode (except for duration) nearly every day during at least a 1-week
period.
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.
The symptoms 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).
Hypomanic
Episode
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.
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:
inflated self-esteem or grandiosity
decreased need for sleep (e.g., feels rested after only 3 hours of
sleep)
more talkative than usual or pressure to keep talking
flight of ideas or subjective experience that thoughts are racing
distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli)
increase in goal-directed activity (either socially, at work or school,
or sexually) or psychomotor agitation
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)
The episode is associated with an unequivocal change in functioning
that is uncharacteristic of the person when not symptomatic.
The disturbance in mood and the change in functioning are observable
by others.
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.
The symptoms 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).
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.
Criteria for Bipolar II Disorder
Presence (or history) of one or more Major Depressive Episodes.
Presence
(or history) of at least one Hypomanic Episode.
There
has never been a Manic Episode or a Mixed Episode.
The
mood episodes in Criteria A and B are not better accounted for by
Schizoaffective Disorder and is not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
Not Otherwise Specified.
The
symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Criteria For Mood Episodes
Major Depressive Episode
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.
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.
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)
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.
insomnia or hypersomnia nearly every day
psychomotor agitation or retardation nearly every day (observable
by others, not merely subjective feelings of restlessness or being
slowed down)
fatigue or loss of energy nearly every day
feelings of worthlessness or excessive or inappropriate guilt (which
may be delusional) nearly every day (not merely self-reproach or guilt
about being sick)
diminished ability to think or concentrate, or indecisiveness, nearly
every day (either by subjective account or as observed by others)
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
The
symptoms do not meet criteria for a Mixed Episode
The
symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
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).
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
A distinct period of abnormally and persistently elevated, expansive,
or irritable mood, lasting at least 1 week (or any duration if hospitalization
is necessary).
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:
inflated self-esteem or grandiosity
decreased need for sleep (e.g., feels rested after only 3 hours of
sleep)
more talkative than usual or pressure to keep talking
flight of ideas or subjective experience that thoughts are racing
distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli)
increase in goal-directed activity (either socially, at work or school,
or sexually) or psychomotor agitation
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)
The
symptoms do not meet criteria for a Mixed Episode
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.
The
symptoms 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).
Mixed
Episode
The criteria are met both for a Manic Episode and for a Major Depressive
Episode (except for duration) nearly every day during at least a 1-week
period.
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.
The
symptoms 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).
Hypomanic
Episode
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.
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:
inflated self-esteem or grandiosity
decreased need for sleep (e.g., feels rested after only 3 hours of
sleep)
more talkative than usual or pressure to keep talking
flight of ideas or subjective experience that thoughts are racing
distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli)
increase in goal-directed activity (either socially, at work or school,
or sexually) or psychomotor agitation
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)
The
episode is associated with an unequivocal change in functioning that
is uncharacteristic of the person when not symptomatic.
The
disturbance in mood and the change in functioning are observable by
others.
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.
The
symptoms 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).
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.
European Description
Bipolar Affective Disorder
This disorder is characterized by repeated (i.e. at least two) episodes
in which the patient's mood and activity levels are significantly
disturbed, this disturbance consisting on some occasions of an elevation
of mood and increased energy and activity (mania or hypomania), and
on others of a lowering of mood and decreased energy and activity
(depression). Characteristically, recovery is usually complete between
episodes, and the incidence in the two sexes is more nearly equal
than in other mood disorders. As patients who suffer only from repeated
episodes of mania are comparatively rare, and resemble (in their family
history, premorbid personality, age of onset, and long-term prognosis)
those who also have at least occasional episodes of depression, such
patients are classified as bipolar.
Manic
episodes usually begin abruptly and last for between 2 weeks and 4-5
months (median duration about 4 months). Depressions tend to last
longer (median length about 6 months), though rarely for more than
a year, except in the elderly. Episodes of both kinds often follow
stressful life events or other mental trauma, but the presence of
such stress is not essential for the diagnosis. The first episode
may occur at any age from childhood to old age. The frequency of episodes
and the pattern of remissions and relapses are both very variable,
though remissions tend to get shorter as time goes on and depressions
to become commoner and longer lasting after middle age.
Although
the original concept of "manic-depressive psychosis" also
included patients who suffered only from depression, the term "manic-depressive
disorder or psychosis" is now used mainly as a synonym for bipolar
disorder.
Includes:
* manic-depressive illness, psychosis or reaction
Excludes:
* bipolar disorder, single manic episode
* cyclothymia
F31.6
Bipolar Affective Disorder, Current Episode Mixed
The patient has had at least one manic, hypomanic, or mixed affective
episode in the past and currently exhibits either a mixture of a rapid
alternation of manic, hypomanic, and depressive symptoms.
Diagnostic
Guidelines
Although the most typical form of bipolar disorder consists of alternating
manic and depressive episodes separated by periods of normal mood,
it is not uncommon for depressive mood to be accompanied for days
or weeks on end by overactivity and pressure of speech, or for a manic
mood and grandiosity to be accompanied by agitation and loss of energy
and libido. Depressive symptoms and symptoms of hypomania or mania
may also alternate rapidly, from day to day or even from hour to hour.
A diagnosis of mixed bipolar affective disorder should be made only
if the two sets of symptoms are both prominent for the greater part
of the current episode of illness, and if that episode has lasted
for a least 2 weeks.
Excludes:
* single mixed affective episode
F30
Manic Episode
Three degrees of severity are specified here, sharing the common underlying
characteristics of elevated mood, and an increase in the quantity
and speed of physical and mental activity. All the subdivisions of
this category should be used only for a single manic episode. If previous
or subsequent affective episodes (depressive, manic, or hypomanic),
the disorder should be coded under bipolar affective disorder.
Includes:
* bipolar disorder, single manic episode
F30.0
Hypomania
Hypomania is a lesser degree of mania, in which abnormalities of mood
and behaviour are too persistent and marked to be included under cyclothymia
but are not accompanied by hallucinations or delusions. There is a
persistent mild elevation of mood (for at least several days on end),
increased energy and activity, and usually marked feelings of well-being
and both physical and mental efficiency. Increased sociability, talkativeness,
overfamiliarity, increased sexual energy, and a decreased need for
sleep are often present but not to the extent that they lead to severe
disruption of work or result in social rejection. Irritability, conceit,
and boorish behaviour may take the place of the more usual euphoric
sociability.
Concentration
and attention may be impaired, thus diminishing the ability to settle
down to work or to relaxation and leisure, but this may not prevent
the appearance of interests in quite new ventures and activities,
or mild over-spending.
Diagnostic
Guidelines
Several of the features mentioned above, consistent with elevated
or changed mood and increased activity, should be present for at least
several days on end, to a degree and with a persistence greater than
described for cyclothymia. Considerable interference with work or
social activity is consistent with a diagnosis of hypomania, but if
disruption of these is severe or complete, mania should be diagnosed.
Differential
Diagnosis
Hypomania covers the range of disorders of mood and level of activities
between cyclothymia and mania. The increased activity and restlessness
(and often weight loss) must be distinguished from the same symptoms
occurring in hyperthyroidism and anorexia nervosa; early states of
"agitated depression", particularly in late middle-age,
may bear a superficial resemblance to hypomania of the irritable variety.
Patients with severe obsessional symptoms may be active part of the
night completing their domestic cleaning rituals, but their affect
will usually be the opposite of that described here.
When
a short period of hypomania occurs as a prelude to or aftermath of
mania, it is usually not worth specifying the hypomania separately.
F30.1
Mania Without Psychotic Symptoms
Mood is elevated out of keeping with the individual's circumstances
and may vary from carefree joviality to almost uncontrollable excitement.
Elation is accompanied by increased energy, resulting in overactivity,
pressure of speech, and a decreased need for sleep. Normal social
inhibitions are lost, attention cannot be sustained, and there is
often marked distractability. Self-esteem is inflated, and grandiose
or over-optimistic ideas are freely expressed.
Perceptual
disorders may occur, such as the appreciation of colours as especially
vivid (and usually beautiful), a preoccupation with fine details of
surfaces or textures, and subjective hyperacusis. The individual may
embark on extravagant and impractical schemes, spend money recklessly,
or become aggressive, amorous, or facetious in inappropriate circumstances.
In some manic episodes the mood is irritable and suspicious rather
than elated. The first attack occurs most commonly between the ages
of 15 and 30 years, but may occur at any age from late childhood to
the seventh or eighth decade.
Diagnostic
Guidelines
The episode should last for at least 1 week and should be severe enough
to disrupt ordinary work and social activities more or less completely.
The mood change should be accompanied by increased energy and several
of the symptoms referred to above (particularly pressure of speech,
decreased need for sleep, grandiosity, and excessive optimism).
F30.2
Mania With Psychotic Symptoms
The clinical picture is that of a more severe form of mania as described
above. Inflated self-esteem and grandiose ideas may develop into delusions,
and irritability and suspiciousness into delusions of persecution.
In severe cases, grandiose or religious delusions of identity or role
may be prominent, and flight of ideas and pressure of speech may result
in the individual becoming incomprehensible. Severe and sustained
physical activity and excitement may result in aggression or violence,
and neglect of eating, drinking, and personal hygiene may result in
dangerous states of dehydration and self-neglect. If required, delusions
or hallucinations can be specified as congruent or incongruent with
the mood. "Incongruent" should be taken as including affectively
neutral delusions and hallucinations; for example, delusions of reference
with no guilty or accusatory content, or voices speaking to the individual
about events that have no special emotional significance.
Differential
Diagnosis
One of the commonest problems is differentiation of this disorder
from schizophrenia, particularly if the stages of development through
hypomania have been missed and the patient is seen only at the height
of the illness when widespread delusions, incomprehensible speech,
and violent excitement may obscure the basic disturbance of affect.
Patients with mania that is responding to neuroleptic medication may
present a similar diagnostic problem at the stage when they have returned
to normal levels of physical and mental activity but still have delusions
or hallucinations. Occasional hallucinations or delusions as specified
for schizophrenia may also be classed as mood-incongruent, but if
these symptoms are prominent and persistent, the diagnosis of schizoaffective
disorder is more likely to be appropriate.
Includes:
* manic stupor
F32
Depressive Episode
In typical depressive episodes of all three varieties described below
(mild, moderate, and severe), the individual usually suffers from
depressed mood, loss of interest and enjoyment, and reduced energy
leading to increased fatiguability and diminished activity. Marked
tiredness after only slight effort is common. Other common symptoms
are:
(a)
reduced concentration and attention;
(b) reduced self-esteem and self-confidence;
(c) ideas of guilt and unworthiness (even in a mild type of episode);
(d) bleak and pessimistic views of the future;
(e) ideas or acts of self-harm or suicide;
(f) disturbed sleep;
(g) diminished appetite.
The
lowered mood varies little from day to day, and is often unresponsive
to circumstances, yet may show a characteristic diurnal variation
as the day goes on. As with manic episodes, the clinical presentation
shows marked individual variations, and atypical presentations are
particularly common in adolescence. In some cases, anxiety, distress,
and motor agitation may be more prominent at times than the depression,
and the mood change may also be masked by added features such as irritability,
excessive consumption of alcohol, histrionic behaviour, and exacerbation
of pre-existing phobic or obsessional symptoms, or by hypochondriacal
preoccupations. For depressive episodes of all three grades of severity,
a duration of at least 2 weeks is usually required for diagnosis,
but shorter periods may be reasonable if symptoms are unusually severe
and of rapid onset.
Some
of the above symptoms may be marked and develop characteristic features
that are widely regarded as having special clinical significance.
The most typical examples of these "somatic" symptoms are:
loss of interest or pleasure in activities that are normally enjoyable;
lack of emotional reactivity to normally pleasurable surroundings
and events; waking in the morning 2 hours or more before the usual
time; depression worse in the morning; objective evidence of definite
psychomotor retardation or agitation (remarked on or reported by other
people); marked loss of appetite; weight loss (often defined as 5%
or more of body weight in the past month); marked loss of libido.
Usually, this somatic syndrome is not regarded as present unless about
four of these symptoms are definitely present.
The
categories of mild, moderate and severe depressive episodes described
in more detail below should be used only for a single (first) depressive
episode. Further depressive episodes should be classified under one
of the subdivisions of recurrent depressive disorder.
These
grades of severity are specified to cover a wide range of clinical
states that are encountered in different types of psychiatric practice.
Individuals with mild depressive episodes are common in primary care
and general medical settings, whereas psychiatric inpatient units
deal largely with patients suffering from the severe grades.
Acts
of self-harm associated with mood (affective) disorders, most commonly
self-poisoning by prescribed medication, should be recorded by means
of an additional code from Chapter XX of ICD-10 (X60-X84). These codes
do not involve differentiation between attempted suicide and "parasuicide",
since both are included in the general category of self-harm.
Differentiation
between mild, moderate, and severe depressive episodes rests upon
a complicated clinical judgement that involves the number, type, and
severity of symptoms present. The extent of ordinary social and work
activities is often a useful general guide to the likely degree of
severity of the episode, but individual, social, and cultural influences
that disrupt a smooth relationship between severity of symptoms and
social performance are sufficiently common and powerful to make it
unwise to include social performance amongst the essential criteria
of severity.
The
presence of dementia or mental retardation does not rule out the diagnosis
of a treatable depressive episode, but communication difficulties
are likely to make it necessary to rely more than usual for the diagnosis
upon objectively observed somatic symptoms, such as psychomotor retardation,
loss of appetite and weight, and sleep disturbance.
Includes:
* single episodes of depression (without psychotic symptoms), psychogenic
depression or reactive depression)
F32.0
Mild Depressive Episode
Diagnostic Guidelines
Depressed mood, loss of interest and enjoyment, and increased fatiguability
are usually regarded as the most typical symptoms of depression, and
at least two of these, plus at least two of the other symptoms described
above should usually be present for a definite diagnosis. None of
the symptoms should be present to an intense degree. Minimum duration
of the whole episode is about 2 weeks.
An
individual with a mild depressive episode is usually distressed by
the symptoms and has some difficulty in continuing with ordinary work
and social activities, but will probably not cease to function completely.
A
fifth character may be used to specify the presence of the somatic
syndrome:
F32.00
Without somatic symptoms
The criteria for mild depressive episode are fulfilled, and there
are few or none of the somatic symptoms present.
F32.01
With somatic symptoms
The criteria for mild depressive episode are fulfilled, and four or
more of the somatic symptoms are also present. (If only two or three
somatic symptoms are present but they are unusually severe, use of
this category may be justified.)
F32.1
Moderate Depressive Episode
Diagnostic Guidelines
At least two of the three most typical symptoms noted for mild depressive
episode should be present, plus at least three (and preferably four)
of the other symptoms. Several symptoms are likely to be present to
a marked degree, but this is not essential if a particularly wide
variety of symptoms is present overall. Minimum duration of the whole
episode is about 2 weeks.
An
individual with a moderately severe depressive episode will usually
have considerable difficulty in continuing with social, work or domestic
activities.
A
fifth character may be used to specify the occurrence of somatic symptoms:
F32.10
Without somatic symptoms
The criteria for moderate depressive episode are fulfilled, and few
if any of the somatic symptoms are present.
F32.11
With somatic symptoms
The criteria for moderate depressive episode are fulfilled, and four
or more or the somatic symptoms are present. (If only two or three
somatic symptoms are present but they are unusually severe, use of
this category may be justified.)
F32.2
Severe Depressive Episode Without Psychotic Symptoms
In a severe depressive episode, the sufferer usually shows considerable
distress or agitation, unless retardation is a marked feature. Loss
of self-esteem or feelings of uselessness or guilt are likely to be
prominent, and suicide is a distinct danger in particularly severe
cases. It is presumed here that the somatic syndrome will almost always
be present in a severe depressive episode.
Diagnostic
Guidelines
All three of the typical symptoms noted for mild and moderate depressive
episodes should be present, plus at least four other symptoms, some
of which should be of severe intensity. However, if important symptoms
such as agitation or retardation are marked, the patient may be unwilling
or unable to describe many symptoms in detail. An overall grading
of severe episode may still be justified in such instances. The depressive
episode should usually last at least 2 weeks, but if the symptoms
are particularly severe and of very rapid onset, it may be justified
to make this diagnosis after less than 2 weeks.
During
a severe depressive episode it is very unlikely that the sufferer
will be able to continue with social, work, or domestic activities,
except to a very limited extent.
This
category should be used only for single episodes of severe depression
without psychotic symptoms; for further episodes, a subcategory of
recurrent depressive disorder should be used.
Includes:
* single episodes of agitated depression
* melancholia or vital depression without psychotic symptoms
F32.3
Severe Depressive Episode With Psychotic Symptoms
Diagnostic Guidelines
A severe depressive episode which meets the criteria given for severe
depressive episode without psychotic symptoms and in which delusions,
hallucinations, or depressive stupor are present. The delusions usually
involve ideas of sin, poverty, or imminent disasters, responsibility
for which may be assumed by the patient. Auditory or olfactory hallucinations
are usually of defamatory or accusatory voices or of rotting filth
or decomposing flesh. Severe psychomotor retardation may progress
to stupor. If required, delusions or hallucinations may be specified
as mood-congruent or mood-incongruent.
Differential
Diagnosis
Depressive stupor must be differentiated from catatonic schizophrenia,
from dissociative stupor, and from organic forms of stupor. This category
should be used only for single episodes of severe depression with
psychotic symptoms; for further episodes a subcategory of recurrent
depressive disorder should be used.
Includes:
* single episodes of major depression with psychotic symptoms, psychotic
depression, psychogenic depressive psychosis, reactive depressive
psychosis