Diagnostic Requirements #

Mood Disorders refers to a superordinate grouping of Depressive Disorders and Bipolar Disorders. Mood disorders are defined according to particular types of Mood Episodes and their pattern over time. The primary types of Mood Episodes are:

• Depressive Episode
• Manic Episode
• Mixed Episode
• Hypomanic Episode

Mood Episodes are not independently diagnosable entities, and therefore do not have their own diagnostic codes. Rather, Mood Episodes are the components of Bipolar or Related Disorders and Depressive Disorders.

The sections that follow first describe the characteristics of Mood Episodes. This is followed by the CDDR for Mood Disorders.

Bipolar or Related Disorders include the following:

• 6A60 Bipolar Type I Disorder
• 6A61 Bipolar Type II Disorder
• 6A62 Cyclothymic Disorder
• 6A6Y Other Specified Bipolar or Related Disorders

Depressive Disorders include the following:

• 6A70 Single Episode Depressive Disorder
• 6A71 Recurrent Depressive Disorder
• 6A72 Dysthymic Disorder
• 6A7Y Other Specified Depressive Disorders

6A73 Mixed Depressive and Anxiety Disorder is also included in the section on Depressive Disorders, although it also shares features with Anxiety or Fear-Related Disorders.

CDDR are also provided for GA34.41 Premenstrual Dysphoric Disorder in the section on Depressive Disorders. Premenstrual Dysphoric Disorder is classified in the grouping of Premenstrual Disturbances in the ICD-11 chapter on Diseases of the Genitourinary System, but is secondary-parented here for reference.

For presentations characterized by mood symptoms that do not fulfil the diagnostic requirements for any other disorder in the Mood Disorders grouping, the following diagnosis may be appropriate:

6A8Y Other Specified Mood Disorders

Essential (Required) Features:

• The presentation is characterized by mood symptoms that cannot clearly be described as bipolar or depressive in nature (e.g., marked and persistent irritability in the absence of other clear manic or depressive symptoms).
• The symptoms do not fulfil the diagnostic requirements for any other disorder in the Mood Disorders grouping.
• The symptoms are not better accounted for by another Mental, Behavioural or Neurodevelopmental Disorder (e.g., Schizophrenia or Other Primary Psychotic Disorder, an Anxiety or Fear-Related Disorder, a Disorder Specifically Associated with Stress, Oppositional Defiant Disorder with chronic irritability-anger, Personality Disorder).
• The symptoms and behaviours are not a manifestation of another medical condition and are not due to the effects of a substance or medication (e.g., alcohol, benzodiazepine) on the central nervous system, including withdrawal effects (e.g., from cocaine).
• The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Mood Episode Descriptions #

Depressive Episode抑郁发作 #

Essential (Required) Features: #

• The concurrent presence of at least five of the following characteristic symptoms occurring most of the day, nearly every day during a period lasting at least 2 weeks. At least one symptom from the Affective cluster must be present. Assessment of the presence or absence of symptoms should be made relative to typical functioning of the individual.
• Affective cluster:
  • Depressed mood as reported by the individual (e.g., feeling down, sad) or as observed (e.g., tearful, defeated appearance). In children and adolescents depressed mood can manifest as irritability.
  • Markedly diminished interest or pleasure in activities, especially those normally found to be enjoyable to the individual. The latter may include a reduction in sexual desire.
• Cognitive-behavioural cluster:
  • Reduced ability to concentrate and sustain attention to tasks, or marked indecisiveness.
  • Beliefs of low self-worth or excessive and inappropriate guilt that may be manifestly delusional. This item should not be considered present if guilt or self-reproach is exclusively about being depressed.
  • Hopelessness about the future.
  • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation (with or without a specific plan), or evidence of attempted suicide.
• Neurovegetative cluster:
  • Significantly disrupted sleep (delayed sleep onset, increased frequency of waking during the night, or early morning awakening) or excessive sleep.
  • Significant change in appetite (diminished or increased) or significant weight change (gain or loss).
  • Psychomotor agitation or retardation (observable by others, not merely subjective feelings of restlessness or being slowed down).
  • Reduced energy, fatigue, or marked tiredness following the expenditure of only a minimum of effort.
• The symptoms are not better accounted for by bereavement.
• The symptoms are not a manifestation of another medical condition (e.g., a brain tumour) and are not due to the effects of a substance or medication on the central nervous system (e.g., benzodiazepines), including withdrawal effects (e.g., from stimulants).
• The clinical presentation does not fulfil the diagnostic requirements for a Mixed Episode.
• The mood disturbance results in significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Additional Clinical Features: #

• In some individuals, the affective component of a Depressive Episode may be primarily experienced and expressed as irritability, or as an absence of emotional experience (e.g., ‘emptiness’). These variants in the expression of the affective component can be considered as meeting the depressed mood requirement for a Depressive Episode if they represent a significant change from the individual’s typical functioning.
• In some individuals, particularly those experiencing a Severe Depressive Episode, there may be reluctance to describe certain experiences (e.g., psychotic symptoms) or inability to do so in detail (e.g., due to psychomotor agitation or retardation). In such cases, observations made by the clinician or reported by a collateral informant are important in determining diagnostic status and severity of the episode.
• Depressive Episodes may be associated with increased consumption of alcohol or other substances, exacerbation of pre-existing psychological symptoms (e.g., phobic or obsessional symptoms), or somatic preoccupations.

Boundary with Normality (Threshold): #

• Some depression of mood is a normal reaction to severe adverse life events and problems (e.g., divorce, job loss), and is common in the community. A Depressive Episode is differentiated from this common experience by the severity, range, and duration of symptoms. If the diagnostic requirements for a Depressive Episode listed above are met, a Depressive Episode should still be considered present, even if there are identifiable life events that appear to have triggered the episode.
• A Depressive Episode should not be considered to be present if the individual is exhibiting normal grief symptoms, including some level of depressive symptoms, and the individual has experienced the death of a loved one within the past 6 months, or longer if a more extended period of bereavement is consistent with the normative response for grieving within the individual’s religious and cultural context. Individuals with no history of Depressive Episodes may experience depressive symptoms during bereavement, but this does not appear to indicate an increased risk of subsequently developing a Mood Disorder. However, a Depressive Episode can be superimposed on normal grief. The presence of a Depressive Episode during a period of bereavement is suggested by persistence of constant depressive symptoms a month or more following the loss (i.e., there are no periods of positive mood or enjoyment of activities), severe depressive symptoms such as extreme beliefs of low self-worth and guilt not related to the lost loved one, presence of psychotic symptoms, suicidal ideation, or psychomotor retardation. A prior history of Depressive Disorder or Bipolar Disorder is important to consider in making this distinction.

Developmental Presentations: #

• Depressive Episode is relatively rare in childhood and occurs with similar frequency among boys and girls. After puberty, rates increase significantly and girls are approximately twice as likely as boys to experience a Depressive Episode.
• All of the characteristic features of Depressive Episode can be observed in children and adolescents. As in adults, symptoms of Depressive Episode should represent a change from prior functioning. Assessment of Depressive Episode in younger children in particular is likely to rely on the report of other informants (e.g., parents) regarding signs and symptoms and the extent to which these represent a change from prior functioning.
• Affective cluster: In young children, depressed mood may present as somatic complaints (e.g., headaches, stomachaches), whining, increased separation anxiety, or excessive crying. Depressed mood may sometimes present in children and adolescents as pervasive irritability. However, the presence of irritability is not in and of itself indicative of a Depressive Episode and may indicate the presence of another Mental, Behavioural or Neurodevelopmental Disorder or be a normal reaction to frustration.
• Cognitive-behavioural cluster: As noted, reduced ability to concentrate or sustain attention may manifest as a decline in academic performance, increased time needed to complete school assignments, or an inability to complete assignments. These symptoms of Depressive Episode must be differentiated from problems with attention and concentration in Attention Deficit Hyperactivity Disorder that are not temporally tied to changes in mood or energy.
• Neurovegetative cluster: Hypersomnia and hyperphagia are more common symptoms of a Depressive Episode in adolescents than in adults. Appetite disturbance in children and adolescents may manifest in failure to gain weight as expected for age and development rather than as weight loss.
• Similar to adults, children and adolescents experiencing a Depressive Episode are at increased risk for suicidality. In younger children, suicidality may manifest in passive statements (e.g., ‘I don’t want to be here anymore’) or as themes of death during play, whereas adolescents may make more direct statements regarding their desire to die.
• Self-injurious behaviours that are not explicitly suicidal in terms of lethality or expressed intent may also occur in Depressive Episode in young children and adolescents. Examples include head banging or scratching in young children and cutting or burning in adolescents. If unaddressed, these types of behaviours tend to increase in frequency and intensity over time among children and adolescents with Depressive Disorders.

Boundaries with Other Disorders and Conditions (Differential Diagnosis): #

• Boundary with Mixed Episode: Depressive symptoms in a Mixed Episode may be qualitatively similar to those of Depressive Episode, but in Mixed Episode several prominent depressive symptoms occur simultaneously or alternate rapidly with several prominent manic symptoms such as irritability, racing or crowded thoughts, increased talkativeness, or increased activity.
• Boundary with Attention Deficit Hyperactivity Disorder: Problems with attention and concentration in Attention Deficit Hyperactivity Disorder are persistent over time (i.e., are not episodic) and are not temporally tied to changes in mood or energy. However, Mood Disorders and Attention Deficit Hyperactivity Disorder can co-occur, and both diagnoses may be assigned if the full diagnostic requirements for each are met.
• Boundary with Prolonged Grief Disorder: Prolonged Grief Disorder is a persistent and pervasive grief response following the death of a partner, parent, child, or other person close to the bereaved that persists for an abnormally long period of time following the loss (e.g., at least 6 months) and is characterized by longing for the deceased or persistent preoccupation with the deceased accompanied by intense emotional pain (e.g., sadness, guilt, anger, denial, blame, difficulty accepting the death, feeling one has lost a part of one’s self, an inability to experience positive mood, emotional numbness, difficulty in engaging with social or other activities). Some common symptoms of Prolonged Grief Disorder are similar to those observed in a Depressive Episode (e.g., sadness, loss of interest in activities, social withdrawal, feelings of guilt, suicidal ideation). However, Prolonged Grief Disorder is differentiated from Depressive Episode because symptoms are circumscribed and specifically focused on the loss of the loved one, whereas depressive thoughts and emotional reactions typically encompass multiple areas of life. Further, other common symptoms of Prolonged Grief Disorder (e.g., difficulty accepting the loss, difficulty trusting others, feeling bitter or angry about the loss, feeling as though a part of the individual has died) are not characteristic of a Depressive Episode. The timing of the onset of the symptoms in relation to the loss and whether there is a prior history of a Depressive Disorder or a Bipolar Disorder are important to consider in making this distinction.
• Boundary with Dementia: Older adults experiencing a Depressive Episode may present with memory difficulties and other cognitive symptoms, which can be severe, and it is important to distinguish these symptoms from Dementia. Dementia is an acquired chronic condition characterized by significant cognitive impairment or decline from a previous level of cognitive functioning in two or more cognitive domains (e.g., memory, attention, executive function, language, social cognition, psychomotor speed, visuoperceptual or visuospatial abilities) that is sufficiently severe to interfere with performance or independence in activities of daily living. If memory difficulties and other cognitive symptoms in older adults occur exclusively in the context of Depressive Episode, a diagnosis of Dementia is generally not appropriate. However, a Depressive Episode can be superimposed on Dementia (e.g., when memory difficulties and other cognitive symptoms substantially predate the onset of the Depressive Episode). The timing and rate of onset of the memory difficulties and other cognitive symptoms in relation to other depressive symptoms are important to consider in making this distinction.

Severity and psychotic symptoms specifiers: #

The severity of all current Depressive Episodes should be rated based on the number and severity of the symptoms, as well as the impact that the mood disturbance has on the individual’s functioning.

In addition, Moderate and Severe Depressive Episodes are described as ‘without Psychotic Symptoms’ (i.e., delusions or hallucinations) or ‘with Psychotic Symptoms’. By definition, Mild Depressive Episodes do not include psychotic symptoms.

Delusions during Moderate or Severe Depressive Episodes are commonly persecutory or self-referential (e.g., being pursued by authorities because of imaginary crimes). In addition, delusions of guilt (e.g., falsely blaming oneself for wrongdoings), poverty (e.g., of being bankrupt) and impending disaster (perceived to have been brought on by the individual), as well as somatic (e.g., of having contracted some serious disease) or nihilistic delusions (e.g., believing body organs do not exist) are known to occur. Delusions related to experiences of influence, passivity or control (e.g., the experience that thoughts or actions are not generated by the person, are being placed in one’s mind or withdrawn from one’s mind by others, or that thoughts are being broadcast to others) can also occur, but less commonly than in Schizophrenia and Schizoaffective Disorder. Auditory hallucinations (e.g., derogatory or accusatory voices that berate the patient for supposed weaknesses or sins) are more common than visual (e.g., visions of death or destruction) or olfactory hallucinations (e.g., the smell of rotting flesh).

Psychotic symptoms are often subtle, and the boundary between psychotic symptoms and persistent depressive ruminations or sustained preoccupations is not always clear. Psychotic symptoms may vary in intensity over the course of a Depressive Episode or even over the course of the day. Psychotic symptoms may be intentionally concealed by individuals experiencing a Depressive Episode.

• Mild Depressive Episode:
  • None of the symptoms of a Depressive Episode should be present to an intense degree.
  • The individual is usually distressed by the symptoms and has some difficulty in continuing to function in one of more domains (personal, family, social, educational, occupational, or other important domains).
  • There are no delusions or hallucinations during the episode.
• Moderate Depressive Episode without Psychotic Symptoms:
  • Several symptoms of a Depressive Episode are present to a marked degree, or a large number of depressive symptoms of lesser severity are present overall.
  • The individual typically has considerable difficulty functioning in multiple domains (personal, family, social, educational, occupational, or other important domains).
  • There are no delusions or hallucinations during the episode.
• Moderate Depressive Episode with Psychotic Symptoms:
  • Several symptoms of a Depressive Episode are present to a marked degree, or a large number of depressive symptoms of lesser severity are present overall.
  • The individual typically has considerable difficulty functioning in multiple domains (personal, family, social, educational, occupational, or other important domains).
  • There are delusions or hallucinations during the episode.
• Severe Depressive Episode without Psychotic Symptoms:
  • Many or most symptoms of a Depressive Episode are present to a marked degree, or a smaller number of symptoms are present and manifest to an intense degree.
  • The individual has serious difficulty continuing to function in most domains (personal, family, social, educational, occupational, or other important domains).
  • There are no delusions or hallucinations during the episode.
• Severe Depressive Episode with Psychotic Symptoms:
  • Many or most symptoms of a Depressive Episode are present to a marked degree, or a smaller number of symptoms are present and manifest to an intense degree.
  • The individual has serious difficulty continuing to function in most domains (personal, family, social, educational, occupational, or other important domains).
  • There are delusions or hallucinations during the episode.

Manic Episode躁狂发作 #

Essential (Required) Features: #

• Both of the following features occurring concurrently and persisting for most of the day, nearly every day, during a period of at least 1 week, unless shortened by a treatment intervention.
  • An extreme mood state characterized by euphoria, irritability, or expansiveness that represents a significant change from the individual’s typical mood. Individuals commonly exhibit rapid changes among different mood states (i.e., mood lability).
  • Increased activity or a subjective experience of increased energy that represents a significant change from the individual’s typical level.
• Several of the following symptoms, representing a significant change from the individual’s usual behaviour or subjective state:
  • Increased talkativeness or pressured speech (a feeling of internal pressure to be more talkative).
  • Flight of ideas or experience of rapid or racing thoughts (e.g., thoughts flow rapidly and, in some cases, illogically from one idea to the next; the person reports that their thoughts are rapid or even racing and has difficulty remaining on topic).
  • Increased self-esteem or grandiosity (e.g., the individual believes that he can accomplish tasks well beyond his skill level, or that he is about to become famous). In psychotic presentations of mania, this may be manifested as grandiose delusions.
  • Decreased need for sleep (e.g., the person reports being able to function with only 2 or 3 hours of sleep), as distinct from Insomnia, in which an individual wants to sleep but cannot.
  • Distractibility (e.g., the person cannot stay on task, because attention is drawn to irrelevant or minor environmental stimuli, such as being overly distracted by outside noise during a conversation).
  • Impulsive reckless behaviour (e.g., the individual impulsively pursues pleasurable activities without regard to their potential for negative consequences, or impulsively makes major decisions in the absence of adequate planning).
  • An increase in sexual drive, sociability, or goal-directed activity.
• The symptoms are not a manifestation of another medical condition (e.g., a brain tumour) and are not due to the effects of a substance or medication on the central nervous system (e.g., cocaine, amphetamines), including withdrawal effects.
• The clinical presentation does not fulfil the diagnostic requirements for a Mixed Episode.
• The mood disturbance results in significant impairment in personal, family, social, educational, occupational, or other important areas of functioning, requires intensive treatment (e.g., hospitalization) to prevent harm to self or others, or is accompanied by delusions or hallucinations.

Additional Clinical Features: #

• Manic Episodes may or may not include psychotic symptoms. A wide variety of psychotic symptoms may occur in mania; among the most common are grandiose delusions (e.g., being chosen by God, having special powers or abilities), persecutory delusions, and self-referential delusions (e.g., being conspired against because of one’s special identity or abilities). Delusions related to experiences of influence, passivity or control (e.g., the experience that thoughts or actions are not generated by the person, are being placed in one’s mind or withdrawn from one’s mind by others, or that thoughts are being broadcast to others) may also occur. Hallucinations are less frequent and commonly accompany delusions of persecution or reference. They are usually auditory (e.g., adulatory voices), and less commonly visual (e.g., visions of deities), somatic, or tactile.
• Some patients may exhibit symptoms or impairment in functioning that is sufficiently severe as to require immediate intervention (e.g., treatment with mood-stabilizing medications). As a result, their symptoms may not meet the full duration requirement of a Manic Episode. Episodes that meet the full symptom requirements but last for less than 1 week because they are shortened by a treatment intervention should still be considered Manic Episodes.
• A manic syndrome arising during antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy, transcranial magnetic stimulation) should be considered a Manic Episode if the syndrome persists after the treatment is discontinued and the full diagnostic requirements of a Manic Episode are met after the direct physiological effects of the treatment are likely to have receded.

Boundary with Normality (Threshold): #

• Periods of euphoric or irritable mood that are entirely contextually appropriate (e.g., euphoria after winning a lottery) should not be considered as meeting the mood component of the diagnostic requirements for a Manic Episode.

Developmental Presentations: #

• Manic Episode is rare in childhood and adolescence. It is normal for children to display over-excitement, exuberance, or silliness in contexts such as special occasions, celebrations, or some types of play. Manic Episode should only be considered when these behaviours are episodic and recurrent (or characterized by rapid onset if a first episode), are inappropriate for the context in which they arise, are in excess of what might be expected given the person’s age or developmental level, represent a distinct change from previous functioning, and are associated with significant impairment in personal, family, social, educational, or other important areas of functioning.
• When a Manic Episode occurs in children or adolescents, all of the characteristic features can be observed. The reports of other informants (e.g., parents) are particularly important in the case of children in evaluating the nature of symptoms and the extent to which they represent a change from previous functioning. The extreme mood state characteristic of Manic Episode may manifest as extreme irritability in children and adolescents. Younger children may exhibit excessive or severe tantrums or increased physical aggression (e.g., throwing things, or hitting).
• In children and adolescents, increased distractibility may manifest as a decline in academic performance, increased time needed to complete school assignments, or inability to complete assignments.
• Increased self-esteem or grandiosity associated with a Manic Episode should be differentiated from children’s normal tendency to overestimate their abilities and believe that they have special talents. Grandiose beliefs that are held with clear evidence to the contrary or acted on in such a way that they place the child in danger are more suggestive of Manic Episode. Examples of manifestations of grandiosity include magical or unrealistic ideas (e.g., thinking they can fly) in younger children or overestimation of abilities or talents based on current functioning (e.g., believing they should coach their high school sports team) in adolescents.
• Specific manifestations of increased goal-directed activities associated with Manic Episode may differ across ages. For example, a younger child might build elaborate projects with blocks, while an adolescent might disassemble electronics or appliances.
• As in adults, children and adolescents may engage in impulsive reckless behaviours during a Manic Episode, but these are likely to present differently in children and adolescents based on behavioural repertoire and access to specific activities. For example, a child may exhibit risky play, disregarding possible injury (e.g., running into a busy street, climbing a tall tree, trying to fly), whereas for adolescents, analogous behaviour may include driving fast, spending excessively, or engaging in risky sexual behaviour.

Boundaries with Other Disorders and Conditions (Differential Diagnosis): #

• Boundary with Hypomanic Episode: The symptoms of Manic Episodes may be qualitatively similar to those of Hypomanic Episodes, but, unlike in a Hypomanic Episode, the mood disturbance is sufficiently severe to result in significant impairment in personal, family, social, educational, occupational, or other important areas of functioning or to require intensive treatment (e.g., hospitalization) to prevent harm to self or others, or is accompanied by delusions or hallucinations.
• Boundary with Mixed Episode: Manic symptoms in a Mixed Episode may be qualitatively similar to those of Manic Episode, but in Mixed Episode several prominent manic symptoms occur simultaneously or alternate rapidly with several prominent depressive symptoms such as dysphoric mood, expressed beliefs of worthlessness, hopelessness, or suicidal ideation.
• Boundary with Attention Deficit Hyperactivity Disorder: Many features of Manic Episode such as increased activity, rapid speech and over-talkativeness, distractibility, and impulsivity can be observed in individuals with Attention Deficit Hyperactivity Disorder. Differentiating between these disorders can be particularly challenging among children and adolescents. However, in Attention Deficit Hyperactivity Disorder, symptoms have their onset before the age of 12, are persistent over time (i.e., are not episodic), and are not temporally tied to changes in mood or energy (e.g., are not accompanied by intense mood elevation). However, rates of Attention Deficit Hyperactivity Disorder are substantially elevated as compared to the general population among children and adolescents diagnosed with Bipolar Disorders, and both diagnoses may be assigned if the full diagnostic requirements for each are met.

Mixed Episode混合发作 #

Essential (Required) Features: #

• The presence of several prominent manic and several prominent depressive symptoms consistent with those observed in Manic Episodes and Depressive Episodes, which either occur simultaneously or alternate very rapidly (from day to day or within the same day). Symptoms must include an altered mood state consistent with a Manic and/or Depressive Episode (i.e., depressed, dysphoric, euphoric or expansive mood), and be present most of the day, nearly every day, during a period of at least 2 weeks, unless shortened by a treatment intervention.
• When manic symptoms predominate in a Mixed Episode, common depressive (contrapolar) symptoms are dysphoric mood, expressed beliefs of worthlessness, hopelessness, and suicidal ideation.
• When depressive symptoms predominate in a Mixed Episode, common manic (contrapolar) symptoms are irritability, racing or crowded thoughts, increased talkativeness, and increased activity.
• When depressive and manic symptoms alternate rapidly during a Mixed Episode, such fluctuations may be observed in mood (e.g., between euphoria and sadness or dysphoria), emotional reactivity (e.g., between flat affect and intense or exaggerated reactiveness to emotional stimuli), drive (e.g., alternating periods of increased and decreased activity, verbal expression, sexual desire, or appetite), and cognitive functioning (e.g., periods of activation and inhibition or slowing of thoughts, attention and memory).
• The symptoms are not a manifestation of another medical condition (e.g., a brain tumour) and are not due to the effects of a substance or medication on the central nervous system (e.g., benzodiazepines), including withdrawal effects (e.g., from cocaine).
• The mood disturbance results in significant impairment in personal, family, social, educational, occupational, or other important areas of functioning or is accompanied by delusions or hallucinations.

Additional Clinical Features: #

• Delusions and hallucinations characteristic of both Depressive and Manic Episodes (see above) can occur in Mixed Episodes.
• A mixed syndrome arising during antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy, transcranial magnetic stimulation) should be considered a Mixed Episode if the syndrome persists after the treatment is discontinued and the full diagnostic requirements of a Mixed Episode are met after the direct physiological effects of the treatment are likely to have receded.

Developmental Presentations: #

• There is limited research regarding Mixed Episodes in children and adolescents; however, there is some evidence to suggest that adolescents with Bipolar Disorders may be more likely than adults with Bipolar Disorders to experience Mixed Episodes.

Boundaries with Other Disorders and Conditions (Differential Diagnosis): #

• Boundary with Manic Episode: Manic symptoms in a Mixed Episode may be qualitatively similar to those of Manic Episode, but in Mixed Episode several prominent manic symptoms occur simultaneously or alternate rapidly with several depressive symptoms such as dysphoric mood, expressed beliefs of worthlessness, hopelessness, or suicidal ideation.
• Boundary with Depressive Episode: Depressive symptoms in a Mixed Episode may be qualitatively similar to those of Depressive Episode, but in Mixed Episode several prominent depressive symptoms occur simultaneously or alternate rapidly with several prominent manic symptoms such as irritability, racing or crowded thoughts, increased talkativeness, or increased activity.
• Boundary with Hypomanic Episode: Manic symptoms in a Mixed Episode may be qualitatively similar to those of Hypomanic Episode, but, unlike in a Hypomanic Episode, the mood disturbance in Mixed Episode is sufficiently severe to result in significant impairment in personal, family, social, educational, occupational, or other important areas of functioning or to require intensive treatment (e.g., hospitalization) to prevent harm to self or others, or is accompanied by delusions or hallucinations. Moreover, in Mixed Episode several prominent manic symptoms occur simultaneously or alternate rapidly with several prominent depressive symptoms such as dysphoric mood, expressed beliefs of worthlessness, hopelessness, or suicidal ideation, which are not characteristic of Hypomanic Episode.

Hypomanic Episode轻躁狂发作 #

Essential (Required) Features: #

• Both of the following symptoms occurring concurrently and persisting for most of the day, nearly every day, for at least several days:
  • Persistent elevation of mood or increased irritability that represents a significant change from the individual’s usual range of moods (e.g., the change would be apparent to people who know the individual well). This does not include periods of elevated or irritable mood that are contextually appropriate (e.g., elevated mood after graduating from school or related to falling in love). Rapid shifts among different mood states commonly occur (i.e., mood lability).
  • Increased activity or a subjective experience of increased energy that represents a significant change from the individual’s typical level.
• In addition, several of the following symptoms, representing a significant change from the individual’s usual behaviour (e.g., the change would be apparent to others who know the individual well) or subjective state.
  • Increased talkativeness or pressured speech (a feeling of internal pressure to be more talkative).
  • Flight of ideas or experience of rapid or racing thoughts (e.g., thoughts flow rapidly from one idea to the next; the person reports that her thoughts are rapid or even racing and has difficulty remaining on a topic).
  • Increased self-esteem or grandiosity (e.g., individual is more self-confident than usual).
  • Decreased need for sleep (e.g., the person reports needing less sleep than usual and still feels well-rested). This differs from Insomnia, in which an individual wants to sleep but cannot.
  • Distractibility (e.g., the person has difficulty staying on task, because attention is drawn to irrelevant or minor environmental stimuli, such as being overly distracted by outside noise during a conversation).
  • Impulsive reckless behaviour (e.g., the individual pursues pleasurable activities with little regard to their potential for negative consequences, or makes decisions in the absence of adequate planning).
  • An increase in sexual drive, sociability or goal-directed activity.
• The symptoms are not a manifestation of another medical condition (e.g., a brain tumour) and are not due to the effects of a substance or medication on the central nervous system (e.g., cocaine, amphetamines), including withdrawal effects (e.g., from stimulants).
• The clinical presentation does not fulfil the diagnostic requirements for a Mixed Episode.
• The mood disturbance is not sufficiently severe as to cause marked impairment in occupational functioning or in usual social activities or relationships with others and is not accompanied by delusions or hallucinations.

Additional Clinical Features: #

• A hypomanic syndrome arising during antidepressant treatment (medication, electroconvulsive therapy, light therapy, transcranial magnetic stimulation) should be considered a Hypomanic Episode if the syndrome persists after the treatment is discontinued and the full diagnostic requirements of a Hypomanic Episode are met after the direct physiological effects of the treatment are likely to have receded.

Boundary with Normality (Threshold): #

• Hypomanic Episodes are often difficult to distinguish from normal periods of elevated mood, for example related to positive life events, particularly given that Hypomanic Episodes are not associated with significant functional impairment. In order to be considered a Hypomanic Episode, the symptoms must represent a significant and noticeable change from the individual’s typical mood and behaviour.
• The occurrence of one or more Hypomanic Episodes in the absence of a history of other types of Mood Episodes (i.e., Manic, Depressive, or Mixed Episodes) is not a sufficient basis for a diagnosis of a Mood Disorder.

Developmental Presentations: #

• As in adults, Hypomanic Episode in children and adolescents are similar to, but less severe than, Manic Episode and may present for a shorter period of time. The information in the section on Developmental Presentations for Manic Episode, above, is therefore also applicable to Hypomanic Episode.
• Hypomanic Episode may be difficult to distinguish from developmentally normative behaviours in children and adolescents (e.g., changes in sleep or irritability during adolescence). Factors to consider include the episodicity and a marked, co-occurring, change in cognitions (e.g., racing thoughts) or behaviours (e.g., increased activity level).
• Increased irritability in younger children may be manifest as excessive or more severe tantrums or increased physical aggression (e.g., throwing things, or hitting).

Boundaries with Other Disorders and Conditions (Differential Diagnosis): #

• Boundary with Manic Episode: The symptoms of Hypomanic Episodes may be qualitatively similar to those of Manic Episodes, but the mood disturbance is not sufficiently severe to result in marked impairment in personal, family, social, educational, occupational, or other important areas of functioning or to require intensive treatment (e.g., hospitalization) to prevent harm to self or others, and is not accompanied by delusions or hallucinations.
• Boundary with Mixed Episode: Manic symptoms in a Mixed Episode may be qualitatively similar to those of Hypomanic Episode, but, unlike in a Hypomanic Episode, the mood disturbance in Mixed Episode is sufficiently severe to result in significant impairment in personal, family, social, educational, occupational, or other important areas of functioning or to require intensive treatment (e.g., hospitalization) to prevent harm to self or others, or is accompanied by delusions or hallucinations. Moreover, in Mixed Episode several prominent manic symptoms occur simultaneously or alternate rapidly with several prominent depressive symptoms such as dysphoric mood, expressed beliefs of worthlessness, hopelessness, or suicidal ideation, which are not characteristic of Hypomanic Episode.
• Boundary with Attention Deficit Hyperactivity Disorder: Many features of Hypomanic Episode such as increased activity, rapid speech and over-talkativeness, distractibility, and impulsivity can be observed in individuals with Attention Deficit Hyperactivity Disorder. Differentiating between these disorders can be particularly challenging among children and adolescents. However, in Attention Deficit Hyperactivity Disorder, symptoms have their onset before the age of 12, are persistent over time (i.e., are not episodic), and are not temporally tied to changes in mood or energy (e.g., are not accompanied by mood elevation). However, rates of Attention Deficit Hyperactivity Disorder are substantially elevated as compared to the general population among children and adolescents diagnosed with Bipolar Disorders, and both diagnoses may be assigned if the full diagnostic requirements for each are met.