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Mood Disorders. Part II. Episodes. Major Depressive Episode Manic Episode Hypomanic Episode Mixed Episode These are the building blocks for the mood D/Os. They themselves are not coded, but are the components of the coded D/Os. Major Depressive Disorder (296.xx).

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Episodes l.jpg
Episodes

  • Major Depressive Episode

  • Manic Episode

  • Hypomanic Episode

  • Mixed Episode

    • These are the building blocks for the mood D/Os. They themselves are not coded, but are the components of the coded D/Os.


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Major Depressive Disorder (296.xx)

  • One or more Major Depressive Episodes (i.e. 2 weeks or more of depressed mood + 4 additional symptoms of depression)

  • No history of Manic, Hypomanic or Mixed Episodes


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Major Depressive Disorder (296.xx)

  • Associated features

    • High mortality rate

      • About 15% of those with this disorder commit suicide

  • Culture, Age & Gender

    • There may be different types of symptoms in different cultures

    • There may also be different attitudes in expressing depressive feelings in different cultures

    • Increased somatic complaints in children

    • Increased cognitive symptoms in adults

    • Occurs twice as frequently in women as men


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Major Depressive Disorder (296.xx)

  • Course

    • Can begin at any age

    • Mean onset in mid-20s

    • Variable course in most individuals

    • Episodes end completely in about 2/3 of those diagnosed with this D/O

    • However, the incidence of one episode increases the chance of another episode, with the probability increasing for each subsequent episode (e.g. it gets progressively worse if not treated).


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Major Depressive Disorder (296.xx)

  • Differential diagnosis

    • Rule out medical condition and substance/medication use

    • Differentiate from Dysthymic Disorder by severity, chronicity and persistence

      • Can be given with Maj. Dep. D/O if the symptoms occurred for 2 years without a Depressive Episode, or if the Maj. Dep. D/O is in remission for 2 months before the onset of the Dysthymia


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Major Depressive Disorder (296.xx)

  • Differential diagnosis

    • Schizoaffective Disorder

      • There must be a two week period of psychotic symptoms outside of a mood episode

    • Psychotic D/O

      • There may be some symptoms of depression in those with these D/O. However, if the criteria are met for a Depressive Episode, the addition diagnosis of Depressive D/O NOS is added.


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Major Depressive D/OCourse specifiers

  • 4th Digit

    • 296.2x

      • Single episode

    • 296.3x

      • Recurrent episodes


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Major Depressive D/OSeverity Specifier

  • 5th digit

    • Clinical status of current (or most recent) mood

      • 296.21 Single episode, mild

      • 296.22 Single episode, moderate

      • 296.23Single episode, severe without psychotic symptoms

      • 296.24 Single episode, severe with psychotic symptoms

      • 296.25Single episode, in partial remission

      • 296.26 Single episode, in full remission

      • 296.20 Single episode, unspecified


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Major Depressive & Bipolar D/OFeatures Specifier

  • Catatonic

    • Waxy flexibility or stupor

    • Excessive motor activity that does not appear to be externally influenced

    • Rigid posture

    • Mutism

    • Other peculiarities of voluntary movement

    • Echolalia

    • Echopraxia


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Major Depressive & Bipolar D/OFeatures Specifier

  • Melancholic

    • Loss of pleasure in all or almost all activities

    • Mood does not improve, even when something good happens

    • Distinctive depressed mood (different from bereavement or feeling sad)

    • Depression worse in the morning

    • Early morning awakening

    • Psychomotor retardation or agitation

    • Significant anorexia or weight loss

    • Excessive or inappropriate guilt


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Major Depressive & Bipolar D/OFeatures Specifier

  • Atypical

    • Mood reactivity

    • Significant weight gain or increase in appetite

    • Hypersomnia

    • Leaden paralysis

    • Long standing pattern of interpersonal rejection sensitivity (pathological sensitivity to being rejected by others) resulting in impaired social or occupational functioning


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Major Depressive & Bipolar D/OAdditional Course Specifiers

  • Rapid Cycling

    • 4 episodes of a Mood Episode in the past 12 months

    • There is a 2 month partial or full remission between episodes, or episodes switch to the opposite polarity

  • Longitudinal

    • With full interepisode recovery

    • Without full interepisode recovery


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Major Depressive & Bipolar D/OAdditional Course Specifiers

  • Postpartum onset

    • Depressive episode which occurs within 4 weeks of giving birth

  • Seasonal pattern

    • There is a regular temporal relationship between the onset of the Mood D/O and a particular time of year

    • Full remission occur in between seasonal episodes (or a shift from depression to mania)

    • Seasonal episode outnumber non-seasonal episodes


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Dysthymic Disorder (300.4)

  • 2 years of depressed mood more days than not

  • During periods of depressed mood, at least 2 of the following are present:

    • Poor appetite or over eating

    • Insomnia or hypersomnia

    • Low energy/fatigue

    • Low self esteem

    • Poor concentration or difficulty making decisions

    • Feelings of hopelessness

  • Symptom free intervals last no more than 2 months

  • No Manic, Hypomanic or Mixed Episodes


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Dysthymic Disorder (300.4)

  • Specifiers

    • Early Onset

      • Before age 21 years

      • Increased risk of developing Maj. Dep. D/O

    • Late Onset

      • Age 21 or older

    • With Atypical Features

      • Same criteria as with Maj. Dep. D/O


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Dysthymic Disorder (300.4)

  • Associated features

    • Feelings of inadequacy

    • Generalized loss of interest

    • Social withdrawal

    • Feelings of guilt or brooding about the past

    • Subjective irritability or anger

    • Decreased activity or productiveness


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Dysthymic Disorder (300.4)

  • Culture, Age & Gender

    • Occurs equally in both genders

    • Children & adolescents will present with symptoms of irritability and crankiness

  • Course

    • Early, insidious onset and chronic course

    • May also develop Maj. Dep. D/O

    • Those with Maj. Dep. D/O may not have full inter-episode recovery from depressed symptoms


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Dysthymic Disorder (300.4)

  • Differential Diagnosis

    • Rule out medical condition and substance/medication use

    • Take a careful history of the client’s experiences of depression, as this disorder is hard to tease apart from Major Depressive Disorder

    • May also occur with a Personality Disorder. If so, both are given.


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Depressive Disorder NOS (311)

  • Exhibits depressive features, but does not meet criteria for

    • Maj. Dep. D/O

    • Dysthymic D/O

    • Adj. D/O with Depressed Mood

    • Adj. D/O with Mixed Anxiety & Depressed Mood

  • Or exhibits depressed symptoms about which there is inadequate or contradictory information


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Bipolar I Disorder (296.xx)

  • One or more Manic or Mixed episodes, usually accompanied by Major Depressive Episodes

  • Recurrent episodes are indicated by a shift in polarity or interval between episodes of at least 2 months.


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Bipolar I Disorder (296.xx)

  • Associated features

    • High morbidity

      • Suicide rates is 10% - 15%

      • More likely to occur during Depressive or Mixed state

    • High occurrence of spouse abuse and child abuse

    • Other features

      • School truancy

      • School failure

      • Occupational failure

      • Divorce

      • Episodic antisocial behavior


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Bipolar I Disorder (296.xx)

  • Culture, Age & Gender

    • No differential in race, age, gender or ethnicity

    • Overdiagnosis of Schizophrenia (instead of Bipolar) among some ethnic groups


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Bipolar I Disorder (296.xx)

  • Males

    • First episode tends to be Manic

    • Number of Manic Episodes exceeds number of Depressive Episodes

  • Females

    • First episode tends to be Major Depressive

    • Number of Depressive Episodes tends to outnumber Manic

    • Rapid Cycling is more common in women

    • Women with Bipolar I are at increased risk for additional episodes post-partum


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Bipolar I Disorder (296.xx)

  • Course

    • Age of onset is about 20 years old

    • Recurrent & chronic

      • 90% of those with a Manic Episode will have another

      • 60% - 70% of Manic Episodes immediately follow a Depressive Episode

    • Interval between episodes tends to decrease with age

    • 20% - 30% display mood lability between episodes


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Bipolar I Disorder (296.xx)

  • Familial Pattern

    • Strong genetic influence

      • Some studies indicate an increased risk of 25% in those having one parent with Bipolar D/O, and a 50% - 75% increased risk in those having both parents with Bipolar D/O


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Bipolar I Disorder (296.xx)

  • Differential Diagnosis

    • Rule out medical condition and substance/medication use, yadda, yadda, yadda…

    • Look at severity and intensity to differentiate from a Hypomanic Episode and Cyclothymic Disorder


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Bipolar I Disorder (296.xx)

  • Schizoaffective Disorder

    • There must be a two week period of psychotic symptoms outside of a mood episode

  • Psychotic D/O

    • There may be some symptoms of mania in those with these D/O. However, if the criteria are met for a Manic or Mixed Episode, the addition diagnosis of Bipolar D/O NOS is added.


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Bipolar I D/OMost recent episode Specifier

  • 4th digit

    • 296.0x Single Manic Episode

    • 296.4x Current or most recent episode is Hypomanic or Manic Episode

    • 296.5x Current or most recent episode is a Depressive Episode

    • 296.6x Current or most recent episode is a Mixed Episode

    • 296.7Current or most recent episode is unspecified (Notice there is no fifth digit for this option. It’s the only Mood D/O without one).


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Bipolar I D/OMost recent episode Specifier

  • 5th digit

    • 296.40(This one is a bit different).

      • Bipolar I Disorder, most recent episode Hypomanic AND

      • Bipolar I Disorder, most recent episode Manic, unspecified


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Bipolar I D/OSeverity Specifier

  • 5th digit

    • Clinical status of current (or most recent) mood

      • 296.41 Bipolar I Disorder, most recent episode Manic, Mild

      • 296.42Bipolar I Disorder, most recent episode Manic, Moderate

      • 296.43Bipolar I Disorder, most recent episode Manic, Severe,without psychotic features

      • 296.44 Bipolar I Disorder, most recent episode Manic, Severe,with psychotic features

      • 296.45Bipolar I Disorder, most recent episode Manic, in partial remission

      • 296.46Bipolar I Disorder, most recent episode Manic, in full remission


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Major Depressive & Bipolar D/OFeatures Specifier

  • Catatonic

    • Waxy flexibility or stupor

    • Excessive motor activity that does not appear to be externally influenced

    • Rigid posture

    • Mutism

    • Other peculiarities of voluntary movement

    • Echolalia

    • Echopraxia


Major depressive bipolar d o features specifier33 l.jpg
Major Depressive & Bipolar D/OFeatures Specifier

  • Melancholic

    • Loss of pleasure in all or almost all activities

    • Mood does not improve, even when something good happens

    • Distinctive depressed mood (different from bereavement or feeling sad)

    • Depression worse in the morning

    • Early morning awakening

    • Psychomotor retardation or agitation

    • Significant anorexia or weight loss

    • Excessive or inappropriate guilt


Major depressive bipolar d o features specifier34 l.jpg
Major Depressive & Bipolar D/OFeatures Specifier

  • Atypical

    • Mood reactivity

    • Significant weight gain or increase in appetite

    • Hypersomnia

    • Leaden paralysis

    • Long standing pattern of interpersonal rejection sensitivity (pathological sensitivity to being rejected by others) resulting in impaired social or occupational functioning


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Major Depressive & Bipolar D/OAdditional Course Specifiers

  • Rapid Cycling

    • 4 episodes of a Mood Episode in the past 12 months

    • There is a 2 month partial or full remission between episodes, or episodes switch to the opposite polarity

  • Longitudinal

    • With full interepisode recovery

    • Without full interepisode recovery


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Major Depressive & Bipolar D/OAdditional Course Specifiers

  • Postpartum onset

    • Depressive episode which occurs within 4 weeks of giving birth

  • Seasonal pattern

    • There is a regular temporal relationship between the onset of the Mood D/O and a particular time of year

    • Full remission occur in between seasonal episodes (or a shift from depression to mania)

    • Seasonal episode outnumber non-seasonal episodes


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Bipolar II Disorder (296.89)

  • One or more Major Depressive Episodes, accompanied by at least one Hypomanic Episode

  • Specifiers

    • Hypomanic

      • Used if the current or most recent episode is Hypomanic

    • Depressed

      • Used if the current or most recent episode is Depressive


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Bipolar II Disorder (296.89)

  • Specifiers

    • If the criteria for a Maj. Dep. D/O are met, the following additional specifiers may be used

      • Mild, moderate, severe without psychotic features, severe with psychotic features

      • Catatonic, Melancholic, Atypical, Postpartum onset

    • If the full criteria are not currently met for a Hypomanic or Maj. Dep. Episode, the following specifiers may be used to describe the current clinical state, or the most recent Maj. Dep Episode

      • Partial remission, full remission

      • Catatonic, Melancholic, Atypical, Postpartum onset


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Bipolar II Disorder (296.89)

  • Associated features

    • High morbidity

      • Suicide rates is 10% - 15%

    • Increased risk for truancy, school failure occupational failure and divorce


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Bipolar II Disorder (296.89)

  • Gender features

    • More common in women than in men

    • Males

      • More Hypomanic than Depressive Episodes

    • Females

      • More Depressive Episodes

      • Increased frequency of Rapid Cycling

      • Increased risk of developing D/O post-partum


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Bipolar II Disorder (296.89)

  • Course

    • 60%-70% of the Hypomanic Episodes occur immediately after a Maj. Dep. Episode

    • Interval between episodes tends to decrease with age

    • About 15% of those with this D/O continue to experience some symptoms in between episodes


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Bipolar II Disorder (296.89)

  • Differential Diagnosis

    • Rule out medical condition and substance/medication use, yadda, yadda, yadda…

    • When a person with Maj. Dep. D/O experiences at least one Hypomanic Episode, the diagnosis is changed to Bipolar II

    • Bipolar II is distinguished from Cyclothymia by the presence of one or more Maj. Dep D/O

    • Schizoaffective Disorder & Psychotic D/O

      • Psychotic symptoms must be present outside of a mood episode


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Cyclothymic Disorder (301.13)

  • 2 years of numerous hypomanic symptoms that do not meet the criteria for a Manic Episode, and numerous periods of depressive symptoms that do not meet the criteria for a Major Depressive Episode

  • During the 2 years, there can be no Maj. Dep., Manic, or Hypomanic Episodes


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Cyclothymic Disorder (301.13)

  • Age & Gender features

    • Begins early in life

    • Occurs equally in men and women

  • Course

    • Begins in adolescence or early adulthood

    • Insidious onset and chronic course


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Cyclothymic Disorder (301.13)

  • Differential Diagnosis

    • One more time, rule out medical condition and substance/medication use.

      • Specifically, a late onset of Cyclothymia may suggest a Mood D/O due to a general medical condition

    • Distinguished from Bipolar I or II with rapid cycling when the mood states do not meet the full criteria for a Maj. Dep, Manic or Mixed Episode

    • Make sure you consider Borderline Personality Disorder, which usually presents with labile and variable mood


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Bipolar Disorder, NOS (296.80)

  • Exhibits bipolar features, but does not meet criteria for any specific Bipolar Disorder

  • Exhibits bipolar symptoms about which there is inadequate or contradictory information


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Mood Disorder due to a …(list the General Medical Condition) (293.83)

  • Exhibits prominent and persistent mood disturbance that is a direct physiological consequence of a General Medical Condition (Code condition on Axis III)

  • Specifiers include

    • With Depressive Features

    • With Major Depressive-like Episode

    • With Manic Features

    • With Mixed Features


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Substance Induced Mood Disorder 29x.xx (Coding is dependent on the type of drug used)

  • Exhibits prominent and persistent mood disturbance that is a direct physiological consequence of a drug of abuse, a medication another somatic treatment for depression or toxin exposure

  • Specifiers include

    • With Depressive Features

    • With Manic Features

    • With Mixed Features

    • With onset during intoxication

    • With onset during withdrawal


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Mood Disorder NOS (296.90) on the type of drug used)

  • Use for coding disorders with mood symptoms that do not meet criteria for any other Mood D/O, and for which it is hard to choose between Depressive Disorder NOS and Bipolar Disorder, NOS.


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