Many meaningful updates and alterations from the DSM-IV to the DSM-V will impact clinical diagnosis and treatment decision-making. One interesting major update falls within the mood disorders category. Mood disorders are disorders that severely impact emotional regulation and function, traditionally including all types of bipolar and depressive disorders.
Depressive and Bipolar Disorders Now Classified Separately
All classifications for depressive and bipolar disorders were previously included in a single mood disorders category in the DSM-IV. The DSM-V expanded these classifications into 2 separate sections: bipolar and depressive disorders. These sections now feature a mixed categorical-dimensional approach with new assessment tools for clinical diagnosis.
The bipolar disorder classifications remain the same: bipolar I, bipolar II, cyclothymic disorders, and bipolar disorder due to medications, drugs, or a medical condition. No major changes other than being pulled into their own section. This is a logical recategorization.
Major depressive disorder and depressive disorder due to another medical condition are included in the depressive disorders group. Major depressive disorder is categorized by the prevalence of depressive mood or loss of interest or pleasure in usual activities, accompanied by other symptoms, including: insomnia or hypersomnia, fatigue or loss of energy, significant weight loss or weight gain, psychomotor agitation or retardation, diminished ability to concentrate or indecisiveness, feelings of worthlessness or excessive guilt, and suicidal ideation, thoughts of death, or attempts at suicide.
Three New Depressive Disorders
Three new depressive disorders are now defined: disruptive mood dysregulation disorder, persistent depressive disorder, and premenstrual dysphoric disorder.
Disruptive Mood Dysregulation Disorder
The only new depressive disorder classification, disruptive mood dysregulation disorder (DMDD) is a childhood disorder diagnosed between ages 6 and 18 classified as “…chronic, severe persistent irritability” (Depressive Disorders: DSM-V Selections). It features abrupt and severe outbursts of temper that are inappropriate or inconsistent with the child’s developmental level, and disproportionate to the provocation or situation. The outbursts must occur frequently, and the child must display a persistently irritable mood in between outbursts with no indication of manic or hypomanic episodes. DMDD cannot coexist with intermittent explosive disorder, oppositional defiant disorder, or bipolar disorder; however, it can coexist with major depressive disorder, attention-deficit hyperactivity disorder, conduct disorder, as well as substance use disorders.
With the DSM-IV, bipolar disorders were diagnosed for cases of episodic mania as well as non-episodic, persistent irritability. This classification offers a distinct category for individuals exhibiting this severe, non-episodic irritability. Currently DMDD is considered uncommon and frequently co-occurs with other disorders. Further research shows that childhood diagnoses of DMDD predict a higher likelihood of diagnosis of one or more adult psychiatric disorders later on.
Persistent Depressive Disorder (Dysthymia)
Persistent depressive disorder (PDD) is a consolidation of the DSM-IV chronic major depressive disorder and dysthymic disorder. The diagnostic criteria are the same as DSM-IV criteria for dysthymia with the addition of major depressive disorder that has been observed for over 2 years. Dysthymia is categorized by depressive mood for most of the day lasting at least 2 years, with the presence of two or more of the following symptoms: insomnia or hypersomnia, fatigue or energy loss, overeating or poor appetite, difficulty making decisions or inability to concentrate, feelings of hopelessness, and low self-esteem.
The organization and diagnostic instructions offer significant overlap with major depressive disorder; although there are four MDD symptoms not present in the PDD criteria. MDD persisting for more than 2 years should be classified as a dual diagnosis with persistent depressive disorder. Additionally, PDD cases that show the presence of a major depressive episode at any point should be noted as a specifier for a PDD diagnosis rather than a separate diagnosis.
This disorder was moved from Appendix B of the DSM-IV to the main text, and the diagnostic criteria has been modified. Premenstrual dysphoric disorder (PDD) is categorized by onset of symptoms in the week before menstruation, improvement within a few days after onset of menses, and resolution of symptoms in the week following menstruation. Symptoms include markedly depressed mood, hypersomnia or insomnia, significant change in appetite, difficulty concentrating, and decreased interest in usual activities, among others.
Specifier Modifications
Specifiers for both bipolar and depressive disorders are outlined to help identify subgroups of the disorders that have significance in symptom pattern and treatment decision-making. The following specifiers remain the same from the DSM-IV:
- Seasonal pattern
- Melancholic features
- Mood-congruent / mood-incongruent psychotic features
- Catatonia
There has also been the addition of a new specifier and a small modification to an existing specifier:
- Peripartum onset: This specifier was changed from “postpartum onset” in the DSM-IV to identify depressive disorders that develop during pregnancy. This should improve recognition of depressive episodes that occur during pregnancy to help prevent postpartum psychosis.
- Anxious distress: This is the only new specifier added in the DSM-V. Anxious distress was added in response to substantial research highlighting the prevalence and importance of anxiety in treatment options for individuals with a bipolar or depressive disorder; anxiety has been identified as a key risk factor for suicide. Encouraging the identification of anxiety in these disorders should aid in suicide prevention.
Implications of the Updates to the Mood Disorders
The changes in depressive disorder criteria are minor, and implications for clinical diagnosis and treatment appear to be modest. The most significant change is the addition of a specific classification for disruptive mood dysregulation disorder, separating bipolar disorder from instances of chronic irritability without the presence of manic episodes. Overall, the changes made will aid in more relevant clinical diagnoses and effective treatment applications.
