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The New DSM-5: Depressive and Bipolar Disorders

C. E. Zupanick, Psy.D.

Introduction:

Aside from reclassification, the changes to bipolar disorder are relatively minor, and primarily conceptual in nature. We still have the three main diagnoses: Bipolar I, Bipolar II, and Cyclothymic. Children who previously received bipolar disorder may now meet the criteria for a new disorder called Disruptive Mood Dysregulation Disorder. It is categorized with Depressive Disorders and is discussed in that section.

DSM-5:  Bipolar and Related Disorders

In DSM-IV, Criterion A for Manic Episode included elevated, expansive and irritable mood. In addition to elevated mood, DSM-5 added changes in energy and activity levels. This broadened inclusion was made because changes in energy and activity are more readily observed and reported in early stages of the disorder. The goal was to improve diagnostic accuracy and to facilitate early detection and treatment. Opponents object to this broadened inclusion, fearing more people may be prematurely diagnosed and improperly medicated.

Another change is the addition of a new disorder called, “Other Specified Bipolar and Related Disorder.” As mentioned in other newsletters, the authors of DSM-5 wanted to tighten up the ‘kitchen sink’ use of NOS (not otherwise specified) diagnoses across all disorders. This new diagnosis captures individuals who previously would have received a Mood Disorder NOS because they did not meet the full criteria for Bipolar II. This new diagnosis is applied to people who otherwise meet criteria for Bipolar II, except for the 4-day hypomanic duration criteria. It is also used for individuals who nearly meet Bipolar II criteria except for the required number of symptoms.

Specifiers: The bipolar I ‘most recent episode mixed’, has been removed. A new specifier has been added, with mixed features. This new specifier no longer requires the full criteria for both depressive and manic episodes. This specifier is also bilateral. It can be added to manic episodes with depressive features and it can be added to depressive episodes with manic or hypomanic features.

A new anxious distress specifier has been added. Like the new ‘with mixed features’ specifier, the anxious distress specifier may be used with both bipolar and depressive disorders. The reason for the inclusion of this new specifier is research suggests that anxious distress affects treatment outcomes; typically predicting a poorer prognosis across a variety of disorders.

DSM-5: Depressive Disorders

The changes to Depressive Disorders are a bit more substantial. There are now four main disorders, rather than just two. We still have Major Depressive Disorder and Dysthymia; though, this is now called Persistent Depressive Disorder. As the name implies, Persistent Depressive Disorder features chronicity as its defining symptom. It includes not only what was formerly known as Dysthymia, but also chronic Major Depression. Research has been unable to find meaningful differences between the two. This change resulted from a broader reconceptualization of chronicity, noting that chronicity affects treatment outcomes, predicting a poorer prognosis.

Two new disorders have been added: Disruptive Mood Dysregulation and Premenstrual Dysphoric Disorder. For those of you who poked around in Appendix B of DSM-IV (disorders proposed for further study), Premenstrual Dysphoric Disorder will be familiar. It was promoted to a full-fledged disorder for inclusion in the Depressive Disorders category.

The DSM-5 no longer has a separate category of disorders for children. Instead, disorders are grouped together into diagnostic categories that share similar features and presumed etiologies. The new Disruptive Mood Dysregulation Disorder is our first example of this. This disorder applies to children up to age 18 with persistent and frequent irritable episodes of behavioral dysregulation. Such children were often diagnosed with bipolar disorder. The addition of this new disorder is in response to growing concerns that children have been overmedicated due to the premature, overdiagnosis of bipolar disorder.

The Grief/Bereavement exclusion for depression has been removed!  Clinical practitioners are likely to welcome this change. Previously, despite meeting all the criteria for a major en removeddepressive episode, this diagnosis could not be applied until two months after the death of a loved one. This exclusion was removed for several reasons: 1) It incorrectly implied that normal grief lasts only two months when it is widely recognized that one to two years is more common. 2) Bereavement is a severe psychosocial stressor that can easily precipitate a major depressive episode, along with all the risks such as suicide. 3) Bereavement-related depression demonstrates similar genetic influences as non-bereavement depression. 4) Symptoms of bereavement-related depression respond to treatment in the same manner as non-bereavement depression.

In addition, a Persistent Complex Bereavement Disorder has been added to the appendix for further study. A footnote will be added to Major Depressive Disorder to aid clinicians in distinguishing between normal grief and a major depressive episode.

We will continue to have a featured topic center entitled, Depression, and one entitled Bipolar Disorders. The content of these two topics centers will be revised to be consistent with DSM-5 diagnostic criteria. Furthermore, content will be updated to reflect contemporary practice and research. The new disorders will be added and discussed. We will remove references to unipolar depression. Topic centers addressing grief and loss will be revised to include a brief discussion of major depression, with links to the Depression Topic Center for more detailed information.

Although DSM-5 no longer has a category for Children and Adolescents, we will continue to maintain a featured topic center that includes the types of disorders and difficulties commonly affecting children and their caregivers. Some information in this topic center will be accessed via links to other portions of the website. For instance, the new diagnosis called Disruptive Mood Dysregulation Disorder is only applicable to children 18 years or younger. Consistent with DSM-5, it will be housed with Depressive Disorders. However, readers can easily access information about this disorder from both the Child and Adolescent Topic Center and from the Depression Topic Center.