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Bipolar and Related Disorders and Depressive Disorders in DSM-5

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Bipolar and Related Disorders and Depressive Disorders in DSM-5 Should be cited as: Psychiatr. Pol. 2014; 48(2): 245–260 PL ISSN 0033-2674 www.psychiatriapolska.pl Bipolar and related disorders and depressive disorders in DSM-5 Dorota Łojko, Aleksandra Suwalska, Janusz Rybakowski Department of Adult Psychiatry, Poznań University of Medical Sciences Head: prof. dr hab. n. med. J. Rybakowski Summary In 2013, a version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), having number 5, was published. The DSM is a textbook which aims to present diagnostic criteria for each psychiatric disorder recognized by the U.S. healthcare system. The DSM-5 comprises the most updated diagnostic criteria of psychiatric disorders as well as their de- scription, and provides a common language for clinicians to communicate about the patients. Diagnostic criteria of the DSM-5 have been popular all over the world, including countries where the ICD-10 classification is obligatory, and are widely used for clinical and neurobio- logical research in psychiatry. In this article, two chapters of the DSM-5 pertained to mood (affective) disorders are presented, such as “Bipolar and related disorders” and “Depressive disorders” replacing the chapter titled “Mood disorders” in the previous version of DSM-IV. The aim of this article is to discuss a structure of new classification, to point out differences compared with previous version (DSM-IV). New diagnostic categories, such as e.g. disrup- tive mood dysregulation disorder or premenstrual dysphoric disorder were depicted as well as some elements of dimensional approach to mood disorders were presented. Key words: bipolar disorders, depressive disorders, DSM-5 Introduction In May 2013, after 14 years of workings, a succeeding version of Diagnostic and Statistical Manual of Mental Disorders, number five (DSM-5), was introduced [1]. The DSM is a textbook aiming to present diagnostic criteria of all mental disor- ders recognized in the health system of the United States. In addition, the textbook provides descriptions of each diagnostic category what makes it a valuable tool for obtaining statistical data and is helpful for all health professionals to communicate. The list of mental disorders, their classification and diagnostic criteria came into existence after many years of work of many experts from multiple panels, analysing 246 Dorota Łojko et al. the results of research, clinical reviews etc. This process can be observed on the web page www.dsm5.org The DSM-5 issued in 2013 comprises the most updated diagnostics criteria of mental disorders and their description, and provides a common updated language for clinicians to communicate about their patients. International Classification of Diseases (ICD) contains code numbers used in DSM-5 and medicine in general, necessary for monitoring morbidity and mortality statistics and for insurance purposes. Since diagnostics criteria of the DSM have gained a considerable popularity all over the world, including countries with obligatory classification of the ICD-10 [2], and are widely used in clinical and neurobiological research in psychiatry, it seems purposeful to acquaint Polish psychiatrists, as soon as possible, with new DSM-5 classification. In the current article, two DSM-5 chapters will be discussed, namely “Bipolar and related disorders” and “depressive disorders”, which replaced the chapter titled “Mood disorders” in the previous version of DSM-IV [3]. The aim of the article is to discuss the structure of the DSM-5 classification and to point on the differences from the previous version (DSM-IV). New diagnostic catego- ries as well as some elements of a dimensional approach to mood disorders in the new classification will be presented. The DSM-5 has already been a topic of a number of arguable articles published in recent months in psychiatric literature [4-7]. Bipolar and related disorders Bipolar I disorder Bipolar and related disorders are separated as a distinct chapter in DSM-5 and include: 1. Bipolar I disorder 2. Bipolar II disorder 3. Cyclothymic disorder 4. Substance/medication induced bipolar and related disorder 5. Bipolar and related disorder due to another medical condition 6. Other specified bipolar and related disorder 7. Unspecified bipolar and related disorder In this subchapter, the criteria of manic episode, hypomanic episode and major depressive episode are presented. As the episode of “major” depression denotes de- pression in the course both unipolar and bipolar disorder which meets symptomatic and duration criteria, in this article, the term “depressive episode” will be used. In Bipolar and related disorders and depressive disorders in DSM-5 247 addition, for unipolar disorder the abbreviation UD will be used, and, for bipolar disorder – the BD. For the diagnosis of manic episode, the DSM-5 introduced a change in criterion (A): to diagnose mania it is necessary that a distinct period of abnormally and persis- tently elevated, expansive or irritable mood and abnormally and persistently increased goal-directed activity or energy occurs. There is an added note in the diagnostic criteria for mania: a full manic episode that emerges during antidepressant treatment (medication, electroconvulsive therapy) but persists at fully syndromal level beyond the physiological effect of the treatment is sufficient evidence for manic episode and, therefore, a bipolar I diagnosis. The DSM-IV had one more criterion for manic episode (marked as C) – the exclu- sion of mixed episode. In the DSM-5 there are no description and criteria for mixed episode and there is no such diagnostic category. Mixed state is placed as a specifier and can be used to describe each mood episode (manic, hypomanic and depressive) and will be discussed later in the article. In the criterion (A) for hypomanic episode, the symptom of abnormally and per- sistently increased activity or energy is required. Duration criterion for hypomanic episode is 4 or more days. Short-term hypomania (lasting 1-3 days) [8] is included in DSM-5 section of other specified bipolar and related disorder. Also hypomanic episode that emerges during antidepressant treatment and persists beyond the physiological effect of that treatment is sufficient for diagnosis of hypomanic episode, which may occur in the BD type I. The authors of DSM-5 suggest a caution in making such diagnosis as one or two hypomanic symptoms may not be sufficient for diagnosis of hypomanic episode (for example, increased irritability or agitation can be result of antidepressants use). If hypomanic symptoms cause marked impairment in any area of functioning or if there are psychotic features – manic episode should be diagnosed. Diagnostic criteria for major depressive episode (MDE) are similar for unipolar and bipolar depression. The symptom of hopeless was added to subjective symptoms of depressive mood besides feelings of sad and empty. Duration criteria (2 weeks) for depression remained the same as in the DSM-IV, but two DSM-IV exclusion criteria: mixed episode and bereavement were deleted. This last issue is one of the most controversial concerning changes in the DSM-5 compared to the DSM-IV and has been widely discussed in the psychiatric literature. In DSM-IV, one could diagnose a depressive episode after the death of a loved one if grief is lasting for 2 months or more, characteristic depressive symptoms occur and cause a significant impairment in functioning. DSM-5 suggests to carefully consider a possible presence of depressive episode in addition to the grief response, and, if so, to diagnose depression even after 2 weeks of its symptoms. Such a diagnosis requires 248 Dorota Łojko et al. a clinical experience and taking into account the individual situation of loss as well as cultural norms. In the process of differentiation between grief in bereavement and depressive epi- sode it is emphasized that in grief, feelings of emptiness and loss predominate, while in depression, persistent depressed mood and the inability to anticipate happiness and pleasure (anhedonia). Symptoms of grief (sadness related to thoughts or memories about the lost one) are frequently transient (pangs of grief) and may decrease within days to weeks. In depressive episode depressed mood is more persistent and not tied to specific thoughts or issues. Sadness in grief might be accompanied by positive emotion, and sometimes humor, while in depressive episode pervasive unhappiness and misery is characteristic. The thought content in grief is preoccupied with memo- ries of the deceased, and not with pessimistic ruminations or decreased self-esteem as in depressive episode. Usually, during grief, the self-esteem is preserved, while in depressive episode, feeling of worthless and self-loathing dominate. Feeling guilty in grief usually refers to failed obligations to the deceased person – for example, not visiting the grave or not reminiscing the person frequently enough, etc. During grief, thoughts of death are usually associated with a deceased person, and possibil- ity of “joining” him/her, while in depressive episode, thoughts are associated with terminating one’s own life because of feeling worthless, undeserving of life or unable to cope with the pain of depression. Despite these controversies, it is argued that a possibility to recognize depression in a grief is not a ‘stigma’ or ‘medicalisation’ of it but gives a better opportunity to care for such person, among others, an appropriate use of antidepressants [9]. After presentation of criteria for each mood episode, there are criteria for bipolar disorder type I: (A)- criteria have been met for at least one manic episode; and (B) the occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum or other psychotic disorder. For bipolar and related disorders the DSM-5 suggests diagnostic coding based on type of current or most recent episode and its severity, presence of psychotic features and remission status. Remission can be diagnosed only if full criteria are not currently met for manic, hypomanic and depression episode.
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