ICD-10 Criteria for Bipolar Disorder (cont.)
In typical depressive episodes of all three varieties described below (mild,
moderate, and severe), the individual usually suffers from depressed mood, loss
of interest and enjoyment, and reduced energy leading to increased fatigability
and diminished activity. Marked tiredness after only slight effort is common.
Other common symptoms are:
- reduced concentration and attention;
- reduced self-esteem and self-confidence;
- ideas of guilt and unworthiness (even in a mild type of episode);
- bleak and pessimistic views of the future;
- ideas or acts of self-harm or suicide;
- disturbed sleep;
- diminished appetite.
The lowered mood varies little from day to day, and is often unresponsive to
circumstances, yet may show a characteristic diurnal variation as the day goes
on. As with manic episodes, the clinical presentation shows marked individual
variations, and atypical presentations are particularly common in adolescence.
In some cases, anxiety, distress, and motor agitation may be more prominent at
times than the depression, and the mood change may also be masked by added
features such as irritability, excessive consumption of alcohol, histrionic
behavior, and exacerbation of pre-existing phobic or obsessional symptoms, or
by hypochondriacal preoccupations. For depressive episodes of all three grades
of severity, a duration of at least 2 weeks is usually required for diagnosis,
but shorter periods may be reasonable if symptoms are unusually severe and of
rapid onset.
Some of the above symptoms may be marked and develop characteristic features
that are widely regarded as having special clinical significance. The most
typical examples of these "somatic" symptoms are: loss of interest or
pleasure in activities that are normally enjoyable; lack of emotional
reactivity to normally pleasurable surroundings and events; waking in the
morning 2 hours or more before the usual time; depression worse in the morning;
objective evidence of definite psychomotor retardation or agitation (remarked
on or reported by other people); marked loss of appetite; weight loss (often
defined as 5% or more of body weight in the past month); marked loss of libido.
Usually, this somatic syndrome is not regarded as present unless about four of
these symptoms are definitely present.
The categories of mild, moderate and severe depressive episodes described in
more detail below should be used only for a single (first) depressive episode.
Further depressive episodes should be classified under one of the subdivisions
of recurrent depressive disorder.
These grades of severity are specified to cover a wide range of clinical
states that are encountered in different types of psychiatric practice.
Individuals with mild depressive episodes are common in primary care and
general medical settings, whereas psychiatric inpatient units deal largely with
patients suffering from the severe grades.
Acts of self-harm associated with mood (affective) disorders, most commonly
self-poisoning by prescribed medication, should be recorded by means of an
additional code from Chapter XX of ICD-10 (X60-X84). These codes do not involve
differentiation between attempted suicide and "parasuicide", since
both are included in the general category of self-harm.
Differentiation between mild, moderate, and severe depressive episodes rests
upon a complicated clinical judgment that involves the number, type, and
severity of symptoms present. The extent of ordinary social and work activities
is often a useful general guide to the likely degree of severity of the
episode, but individual, social, and cultural influences that disrupt a smooth
relationship between severity of symptoms and social performance are
sufficiently common and powerful to make it unwise to include social
performance amongst the essential criteria of severity.
The presence of dementia or mental retardation does not rule out the
diagnosis of a treatable depressive episode, but communication difficulties are
likely to make it necessary to rely more than usual for the diagnosis upon
objectively observed somatic symptoms, such as psychomotor retardation, loss of
appetite and weight, and sleep disturbance.
Includes:
single episodes of depression (without psychotic symptoms), psychogenic
depression or reactive depression)
Diagnostic Guidelines
Depressed mood, loss of interest and enjoyment, and increased fatigability
are usually regarded as the most typical symptoms of depression, and at least
two of these, plus at least two of the other symptoms described above should
usually be present for a definite diagnosis. None of the symptoms should be
present to an intense degree. Minimum duration of the whole episode is about 2
weeks.
An individual with a mild depressive episode is usually distressed by the
symptoms and has some difficulty in continuing with ordinary work and social
activities, but will probably not cease to function completely.
A fifth character may be used to specify the presence of the somatic
syndrome:
F32.00: Without somatic symptoms
The criteria for mild depressive episode are fulfilled, and there are few or
none of the somatic symptoms present.
F32.01: With somatic symptoms
The criteria for mild depressive episode are fulfilled, and four or more of
the somatic symptoms are also present. (If only two or three somatic symptoms
are present but they are unusually severe, use of this category may be
justified.)
Diagnostic Guidelines
At least two of the three most typical symptoms noted for mild depressive
episode should be present, plus at least three (and preferably four) of the
other symptoms. Several symptoms are likely to be present to a marked degree,
but this is not essential if a particularly wide variety of symptoms is present
overall. Minimum duration of the whole episode is about 2 weeks.
An individual with a moderately severe depressive episode will usually have
considerable difficulty in continuing with social, work or domestic activities.
A fifth character may be used to specify the occurrence of somatic symptoms:
F32.10 Without somatic symptoms
The criteria for moderate depressive episode are fulfilled, and few if any
of the somatic symptoms are present.
F32.11 With somatic symptoms
The criteria for moderate depressive episode are fulfilled, and four or more
or the somatic symptoms are present. (If only two or three somatic symptoms are
present but they are unusually severe, use of this category may be justified.)
In a severe depressive episode, the sufferer usually shows considerable
distress or agitation, unless retardation is a marked feature. Loss of
self-esteem or feelings of uselessness or guilt are likely to be prominent, and
suicide is a distinct danger in particularly severe cases. It is presumed here
that the somatic syndrome will almost always be present in a severe depressive
episode.
Diagnostic Guidelines
All three of the typical symptoms noted for mild and moderate depressive
episodes should be present, plus at least four other symptoms, some of which
should be of severe intensity. However, if important symptoms such as agitation
or retardation are marked, the patient may be unwilling or unable to describe
many symptoms in detail. An overall grading of severe episode may still be
justified in such instances. The depressive episode should usually last at
least 2 weeks, but if the symptoms are particularly severe and of very rapid
onset, it may be justified to make this diagnosis after less than 2 weeks.
During a severe depressive episode it is very unlikely that the sufferer
will be able to continue with social, work, or domestic activities, except to a
very limited extent.
This category should be used only for single episodes of severe depression
without psychotic symptoms; for further episodes, a subcategory of recurrent
depressive disorder should be used.
Includes:
single episodes of agitated depression
melancholia or vital depression without psychotic symptoms
Diagnostic Guidelines
A severe depressive episode which meets the criteria given for severe
depressive episode without psychotic symptoms and in which delusions,
hallucinations, or depressive stupor are present. The delusions usually involve
ideas of sin, poverty, or imminent disasters, responsibility for which may be
assumed by the patient. Auditory or olfactory hallucinations are usually of
defamatory or accusatory voices or of rotting filth or decomposing flesh.
Severe psychomotor retardation may progress to stupor. If required, delusions
or hallucinations may be specified as mood-congruent or mood-incongruent.
Differential Diagnosis
Depressive stupor must be differentiated from catatonic schizophrenia, from
dissociative stupor, and from organic forms of stupor. This category should be
used only for single episodes of severe depression with psychotic symptoms; for
further episodes a subcategory of recurrent depressive disorder should be used.
Includes:
single episodes of major depression with psychotic symptoms,
psychotic depression, psychogenic depressive psychosis, reactive depressive
psychosis
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