Mood Disorders - Changes from ICD 10 and DSM IV to ICD 11 and DSM 5

1. Mood Disorders- DSM 5, ICD
11
Dr BK Waraich
MD Psychiatry
Consultant Psychiatrist

2. History
Hippocrates (460–379 BC) - Excess of black bile, one of the humors in
the body causes melancholia.
• Galen-referred to Hippocrates’ four types of temperament resulting
from humoral excesses: melancholic (black bile) optimistic (blood),
choleric (yellow bile), and phlegmatic (“phlegm”) melancholia
• Pinel (1745–1826)- Four main groups: Melancholia, Mania, Idiocy, and
Dementia
• 1845, Esquirol- “Monomania” several situations of partial insanity,
characterized by delusion which was limited to one object or to a
restricted number of objects. “lypemania”- ie depressive affect and
“Monomania” ie Expansive Affect

3. 1854, Jules Falret - folie circulaire - alternating moods of depression
and mania.
• 1882, the German psychiatrist Karl Kahlbaum - cyclothymia,
described mania and depression as stages of the same illness.
• In 1899, Emil Kraepelin : – manic-depressive psychosis differentiated
it from dementia praecox (then the name for schizophrenia) –
described Involutional melancholia = a form of mood disorder that
begins in late adulthood
• In the beginning of the twentieth century the term melancholia was
gradually displaced by the term depression,

4. Current Understanding of Melancholia
• Nowadays the term melancholia is - certain cases of severe
depression, usually known as Endogenous Depression.
• Characterized by the presence of profound sadness, anhedonia, loss
of emotional resonance, vegetative symptoms (insomnia, anorexia,
circadian variability in mood), a seasonal pattern, motor retardation
and presence of delusions and/or hallucinations.
• It is thought that the endogenous depression has mainly an organic
cause (with several neurobiological alterations, including
psychoimmunological), and a better response to medication (in
severe cases electroconvulsive therapy) than the Reactive Depression
(also called neurotic or situational depression)

5. • Mood- a Pervasive sustained feeling state- EXPRESSED Externaally
• AFFECT- An immediately expressed and observed emotion(EXTERNAL).
• Common examples of affect are euphoria, anger, and sadness.
• A Range of affect may be described as broad (normal), restricted (constricted),
blunted, or flat.
• The normal expression of affect involves variability in facial expression, pitch of
voice, and the use of hand and body movements. Restricted affect is
characterized by a clear reduction in the expressive range and intensity of
affects. Blunted affect is marked by a severe reduction. In Flat affect there is a
lack of signs of affective expression: the voice may be monotonous and the
face, immobile.
• Affect is Inappropriate when it is clearly discordant with the content of the
person's speech or ideation.
• Affect is labile when it is characterized by repeated, rapid, and abrupt shifts.
Example: An elderly man is tearful one moment and combative the next.

6. • A mood disorder is a mental health problem that primarily affects a
person’s emotional state. It is a disorder in which a person experiences
long periods of extreme happiness, extreme sadness, or both.
• Now divided into two categories in DSM 5 ie Depressive disorders and
Bipolar Disorders.
• Depression includes- Depressive episode,
- Postpartum Depression( part of depressive ep)
-Persistent depressive disorder (dysthymia)
- Recurrent Depressive Disorder
-PMDD (Part of genitourinary disorders in ICD11)
- Mixed episode retained in ICD11 (DSM 5 has a
mixed episode specifier and not a separate disorder)
• Bipolar Disorders- Include- Bipolar 1
- Bipolar 2
- Cyclothymia

7. • World Health Organization (WHO) states that depression is the leading
cause of disability as measured by Years Lived with Disability (YLDs)
• Depression - Female:Male ratio- 2:1; Bipolar D- Female : Male 1:1
- Average age of onset- 40yrs, - 30 yrs
Prevalence- Female 5.5%; Males- 3.8% -Both 1%
Above 65 yrs Females -7.5%, Males 5%

8. SUICIDE
• About 50% of individuals who have committed suicide carried a primary
diagnosis of depression.
• Rates increased from 7 per 100,000 to 16.5 per 100,000.
• 37.8% of those who complete suicide are below 30 yrs of age.
• Suicide was the most common cause of death in both the age groups of 15–29
years and 15–39 years. About 800,000 people die by suicide worldwide every
year, of these 135,000 (17%) are residents of India, a nation with 17.5% of
world population.
• One report says that among men, 40% suicides were by individuals aged 15-
29, while for women it was almost 60% 9 This is in contrast to developed
countries where men complete suicide more often)

9. • ICD 11 retains Mood Disorders category.
• The mood disorders section in ICD-11 has been reorganized, opening
with the description of mood episodes (depressive, manic, mixed and
hypomanic). Mixed Mood Disorder is only as a specifier in DSM 5 not
a separate category.
• Moreover, in the bipolar and related disorders grouping newer
research led to the subdivision of bipolar disorder into types I and II.
This was already there in DSM Iv and has been continued in DSM 5.

10. Major Depressive Episode
• At least 5 of the following symptoms have to have been present during the same 2-week
period (and at least 1 of the symptoms must be diminished interest/pleasure or depressed
mood)[2] :
• Depressed mood: For children and adolescents, this can also be an irritable mood
• Diminished interest or loss of pleasure in almost all activities (anhedonia)
• Significant weight change or appetite disturbance: For children, this can be failure to
achieve expected weight gain
• Sleep disturbance (insomnia or hypersomnia)
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness
• Diminished ability to think or concentrate; indecisiveness
• Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a
suicide attempt or specific plan for committing suicide

11. ICD11
• Includes the omission of reduced energy and fatigue from the
essential features and their inclusion in a “neurovegetative” cluster.
Although this is in line with definitions of depressive episodes in the
DSM-5, the idea of specific clusters of depressive symptoms is unique
to ICD-11 revision. Then again, requirements for a threshold of five
symptoms, one of which is from the “affective cluster” are similar to
the DSM-5 and somewhat different from the ICD-10. In addition,
impairment of role-function has been added as an essential feature.
• Bereavement Exclusion has been removed from DSM 5 but is there in
ICD 11.

12. Specifiers
• With anxious distress (ICD11-Depression with prominent Anxiety symptoms)
• With mixed features
• With rapid cycling
• With melancholic features
• With atypical features
• With mood-congruent psychotic features
• With mood-incongruent psychotic features
• With catatonia
• With peripartum onset
• With seasonal pattern

13. Atypical Depression specifier
• Increased appetite or significant weight gain
• Increased sleep
• Feelings of heaviness in arms or sensitivities of the legs that extend
far beyond the mood disturbance episodes and result in significant
impairment in social or occupational functioning
• A pattern of longstanding interpersonal rejection sensitivity that
extends far beyond the mood disturbance episodes and results in
significant impairment in social or occupational functioning

14. Mixed anxiety and depressive disorder, or ‘MADD’
(ICD10) Or “With Anxious Distress”(DSM IV),
• Included as a separate diagnostic category in ICD-11 ( moved from Anxiety
Disorders to Mood Disorders and renamed ‘Mixed Depressive and Anxiety
Disorder’ (MDAD)(ICD-11, 2019).
• But in DSM 5- no separate category but “the specifier "with anxious distress"
has been added to both depressive and bipolar disorders.
• MADD is characterised in ICD-10 by subsyndromal symptoms of anxiety and
depression (i.e symptoms that are severe enough to justify the diagnosis of
MADD, but neither of which predominate sufficiently to warrant a separate
diagnosis of an anxiety disorder or major depression).

15. Depression with Anxious Distress(DSM 5)
• Feeling keyed up or tense
• Feeling unusually restless
• Difficulty concentrating because of worry
• Fear that something awful may happen
• Feeling of potential loss of control
• Severity is further specified as:
• Mild: Two symptoms
• Moderate: Three symptoms
• Moderate-severe: Four or five symptoms
• Severe: Four or five symptoms with motor agitation

16. Depression With Melancholic Features
• In Depression with melancholic features, either a loss of pleasure in almost
all activities or a lack of reactivity to usually pleasurable stimuli is present.
Additionally, at least 3 of the following are required:
• A depressed mood that is distinctly different from the kind that is felt when
a loved one is deceased
• Depression that is worse in the morning
• Waking up 2 hours earlier than usual
• Observable psychomotor retardation or agitation
• Significant weight loss or anorexia
• Excessive or inappropriate guilt
• According to DSM-5, this subtype is applied only when there is a near-
complete absence of the capacity for pleasure, not merely a diminution.

17. Depression with Catatonic features
• 3 or more of 12 psychomotor features during most of the episode:
• Stupor
• Catalepsy(A body's persistence in unusual postures, with waxy rigidity of the
limbs, and complete inactivity, regardless of outside stimuli)
• Waxy flexibility (they would keep their arm where one moved it until it was
moved again, as if it were made from wax)
• Mutism
• Negativism (Resistance to attempts to move the subject, who then does the
opposite of what is asked) . Gegenhalten is a catatonic phenomenon in which
the subject opposes all passive movements with the same degree of force as
applied by the examiner. It is slightly different from negativism

18. • Posturing
• Mannerism (Normal actions carried out in a complicated or odd way)
• Stereotypy (repetitive or ritualistic movement, posture, or utterance eg
body rocking, or complex, such as self-caressing, crossing and uncrossing of
legs, and marching in place.
• Agitation, not influenced by external stimuli
• Grimacing
• Echolalia (Repetition or echoing of verbal utterances made by another
person.)
• Echopraxia (Repetition of gestures made by another person.

19. Seasonal Depression
• To meet the DSM-5 diagnostic criteria for major depressive disorder with
seasonal pattern, depression should be present only at a specific time of
year (e.g., in the fall or winter) and full remission occurs at a characteristic
time of year (e.g., spring).
• An individual should demonstrate at least 2 episodes of depressive
disturbance in the previous 2 years, and seasonal episodes should
substantially outnumber nonseasonal episodes.
• Patients with seasonal affective disorder are more likely to report Atypical
symptoms, such as hypersomnia, increased appetite, and a craving for
carbohydrates.

20. Major Depressive Disorder with Psychotic Features
• The presentation of severe major depressive disorder may include
psychotic features. Psychotic features include delusions and
hallucination and may be mood congruent or mood incongruent.
• ICD 11 has included a new “Moderate Depressive Disorder with
Psychotic symptoms” thus separating psychotic symptoms from
severity of Depression.

21. Dysthymia
• Dysthymic disorder is a disorder characterized by a persistently
depressed mood that occurs most of the day, for more days than not,
for a period of at least 2 years (at least 1 year or more in children and
adolescents;
• In the DSM it has been re-named Persistent Depressive Disorder.

22. Postpartum Depression
• DSM 5-Major depressive episode “with Peripartum Onset if onset of mood
symptoms occurs during pregnancy or within 4 weeks following delivery” .
• However, depression that begins later than 4 weeks after delivery or does not meet
the full criteria for a major depressive episode may still cause harm and require
treatment. In clinical practice and in clinical research, postpartum depression (i.e.,
nonpsychotic puerperal depression) is variably defined as depression that occurs
within 4 weeks after childbirth, or 3 months, 6 months, or up to 12 months after
childbirth.
• Prevalence of postpartum depression ranges from 6.5 to 12.9%
• Symptoms of postpartum depression often include sleep disturbance (beyond that
associated with the care of the baby), anxiety, irritability, and a feeling of being
overwhelmed, as well as an obsessional preoccupation with the baby’s health and
feeding, Suicidal ideation and worries about causing harm to the baby.

23. • Risk factor for postpartum depression is a history of mood and
anxiety problems and, in particular, untreated depression and anxiety
during pregnancy.
• Causes- The rapid decline in the level of reproductive hormones after
childbirth, genetic factors and social factors including low social
support, marital difficulties, violence involving the intimate partner,
previous abuse, and negative life events
• Baby Blues is mild self limiting depressive symptoms in the first few
days and usually remits within 2 weeks after delivery.

24. Premenstrual Dysphoric Disorder
• In the majority of menstrual cycles, at least five symptoms must be present in
the final week before the onset of menses, start to improve within a few days
after the onset of menses, and become minimal or absent in the week
postmenses.
• Marked depressed mood, feelings of hopelessness, or self-deprecating
thoughts.
• Marked anxiety,
• Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful or
increased sensitivity to rejection).
• Marked irritability, anger
• Also includes bloating, breast tenderness, fatigue, and changes in sleep and
eating habits.

25. Mixed Mood Disorder(ICD 11)
• Criteria for Manic or Hypomanic episode are met . In addition, 3 of the following
are present on most days-
• Prominent dysphoria or depressed mood as indicated by either subjective report
(e.g., feels sad or empty) or observation made by others (e.g., appears tearful);
• Fatigued,
• Diminished interest,
• Psychomotor retardation nearly every day;
• Feelings or worthlessness or excessive ideas of guilt,
• Thoughts of dying, suicidal Ideation or plans
(DSM-5) replaces the diagnosis of “mixed episode” with a mixed-features specifier
that can be applied to episodes of major depression, hypomania or mania. The
separate Mixed episode category has been removed)

26. Mixed Specifier in DSM 5
• The DSM-5 attempts to capture this large proportion of patients with
subsyndromal mixed symptoms with the inclusion of the “mixed specifier.”
The presence of such subsyndromal mixed symptoms has significant
implications for both diagnosis and treatment. For those presenting with
major depressive disorder with subsyndromal manic symptoms, be vigilant
for the development of full-blown bipolar disease.
• Bipolar disorder is often undiagnosed, and patients will often present with
subsyndromal mixed states.
• It is important to ask patients with major depressive disorder if they have
manic symptoms, as this symptom has significant diagnostic and therapeutic
implications.
• Atypical antipsychotics and mood-stabilizing agents can be helpful in the
treatment of both depression with mixed symptoms and mania with mixed
symptoms.

27. • DSM IV had a bereavement exclusion which has been removed in
DSM 5.
• The ICD-11 however excludes from the diagnosis of depressive
episode, in line with the ICD-10, bereavement reactions appropriate
to the individual's cultural and religious background.

28. Manic episode & Hypomanic episode
• Diagnosis of bipolar mood disorders in both ICD-11 & DSM-5 now requires an
essential entry feature not only the presence of elated/euphoric, expansive or
irritable mood but in also, increased activity/energy;
1.Euphoria, Irritability or Expansiveness, and, Increased activity or subjective
experience of Increased Energy
2.Plus “several “(ICD-11), three or more (DSM 5) of the following 7 symptoms:
1.Increased talkativeness or pressured speech,
2.Flight of ideas,
3.Increased self-esteem or grandiosity,
4.Decreased need of sleep,
5.Distractibility,
6.Impulsive reckless behaviour,
7.Increase in sexual drive, sociability or goal-directed activity.

29. Specifiers in DSM 5
• Specify:
• With anxious distress
• With mixed features
• With rapid cycling
• With melancholic features
• With atypical features
• With mood-congruent psychotic features
• With mood-incongruent psychotic features
• With catatonia
• With peripartum onset
• With seasonal pattern

30. Rapid cycling
• The DSM-IV defines rapid cycling bipolar disorder as a pattern of presentation
accompanied by 4 or more mood episodes in a 12-month period, with a typical
course of mania or hypomania followed by depression or vice versa. The
episodes must be demarcated by a full or partial remission lasting at least 2
months or by a switch to a mood state of opposite polarity. Research shows
that it is common for rapid cyclers to have frequent brief depressive episodes
that do not necessarily meet duration criteria.
• Some investigators have further classified rapid cycling into ultrarapid (cycling
every few days) and ultradian (cycling that occurs daily

31. DSM 5 AND ICD 11
• The minimum duration of a hypomanic episode is 4+ days in DSM-5 and
“several days” in ICD-11 For the purposes of our analysis several was
interpreted as 4+ consecutive days.
• A restriction in the definition of a hypomanic episode in DSM-5 relates to
changes in functioning. In DSM-5 criterion C: an unequivocal change in
functioning uncharacteristic of the person, and criterion D: the disturbance in
mood and the change in functioning are observable by others must be met. In
ICD-11 this is less categorically expressed as the significant change in the
usual range of moods and behaviour would be apparent to people who know
the individual well.
• Both now allow the diagnosis of a manic or hypomanic episode if the full
syndrome persists after antidepressant treatment (e.g. medication, ECT, light
therapy) is discontinued and its direct effects have ceased or receded

32. Bipolar I and Bipolar II
• Bipolar II disorder shares many similarities with bipolar I;
• it is characterized by periods of major depression and periods of
elevated mood.
• The primary difference between bipolar II and bipolar I is that a
person with bipolar II has only met criteria for a hypomanic episode
and never a full manic episode (as in bipolar I)
• in their lifetime. The differences between hypomanic and full manic
episodes are in duration (the duration criterion for hypomanic
episodes is shorter [4 days vs. 1 week]) and in functional impairment.
Hypomanic episodes are not accompanied by significant functional
impairment.

33. Cyclothymia
• Cyclothymia causes emotional ups and downs, but they're not as extreme
as those in bipolar I or II disorder.
• Many periods of elevated mood (hypomanic symptoms) and periods of
depressive symptoms for at least two years (one year for children and
teenagers) — with these highs and lows occurring during at least half that
time.
• Periods of stable moods usually last less than two months.
• The symptoms significantly affect socially, at work, at school or in other
important areas.
• The symptoms don't meet the criteria for bipolar disorder, major
depression or another mental disorder.
• The symptoms aren't caused by substance use or a medical condition.

34. Psychoanalytic theories of Depression
• Freud and Karl Abraham-
- Abraham believed that the melancholic patient is fixated on the oral
stage. Secondly, the patient will also have experienced early and
repeated childhood disappointments in love. Abraham viewed
depressed individuals as having suffered an enormous frustration at
the hands of a loved one and therefore unconsciously longing to
destroy the object of affection.
-Freud believes that mourning and melancholia are both a response to
a loss, whether it is a conscious or unconscious one.
-Freud- Depression is Aggression directed Inwards (1930),

35. • In Bibring’s model of depression (1953), depressive
symptoms result from frustrated aspirations and the
experience of helplessness. An individual’s incapacity to
fulfill his or her wishes to be loved, loving, secure, and good,
rather than unworthy of love, insecure, aggressive, and
destructive, leads, according to Bibring, to depression.
• In John Bowlby’s view (1960), Separation from the Mother
induces powerful and intolerable hate in the child. This
unmanageable and unacceptable hate is pushed down and
displaced onto others and the self.

36. • The manic state may result from a tyrannical superego, which
produces intolerable self-criticism that is then replaced by euphoric
self-satisfaction.
• Bertram Lewin regarded the manic patients ego as overwhelmed by
pleasurable impulses, such as sex, or by feared impulses, such as
aggression.
• Melanie Klein also viewed mania as a defensive reaction to
depression, using manic defenses such as omnipotence, in which the
person develops delusions of grandeur.

37. COGNITIVE THEORIES OF DEPRESSION -
AARON BECK
• Negative Self precept
• Negative views about the world
• Negatives views of the future

38. Negative Cognitive Triad
• Beck also believes that there are three main dysfunctional belief themes (or
"schemas") that dominate a person with depression's thinking:
• I am defective or inadequate.
• All of my experiences result in defeats or failures.
• The future is hopeless.
• Particular failures of information processing are very characteristic of the
depressed mind. For example, people with depression will tend to pay attention
to information which matches their negative expectations and ignore information
that goes against those expectations. Faced with a mostly positive performance
review, people with depression will manage to find and focus in on the one
negative comment that keeps the review from being perfect. They tend to
magnify the importance and meaning placed on negative events, and minimize
the importance and meaning of positive events

39. Albert Ellis' Cognitive Theory of Depression
• Irrational beliefs of people with depression tend to take the form of
absolute statements. 3 main irrational beliefs-
-"I must be completely competent in everything I do, or I am worthless."
-"Others must treat me considerately, or they are absolutely terrible."
-"The world should always give me happiness, or I will die.”
• Ellis referred to this tendency towards absolutism in depressive thinking as
"Musterbation.”
• They also tend to engage in Overgeneralization. This happens when people
assume that because a single isolated event has turned out badly, that this
means that all events will turn out badly.
• Ignoring the Positive

40. Albert Bandura's social cognitive theory (SCT)
• people are shaped by the interactions between their behaviors, thoughts,
and environment.
• Those with depression tend to hold themselves completely responsible for
bad things in their lives and are full of self-blame.
• They have Poor Self Efficacy ie do not believe they can change the situation
ie things are outside their control.
• When people believe that they can affect and change their situations, they
may be said to have an internal locus of control and a relatively high sense
of self-efficacy. When individuals feel that they are mostly at the mercy of
the environment and cannot change their situation, they have an external
locus of control, and a relatively low sense of self-efficacy.

41. Martin Seligman learned helplessness
• In a study involved watching what happened when a dog was allowed to
escape an impending, negative but non-damaging electrical shock. They
would not get the shock if they escaped from a specific area of their pen
after hearing a tone. During the first experiment, the researcher rang a bell
immediately before a brief slightly unpleasant sensation to the dog. The
idea was that the dog would learn to associate the tone with the shock. In
the future, the dog would then feel fear when it heard the bell, and would
run away or show some other fear-related behavior after hearing the tone.
• Second part Dog was put in an environment where they could escape the
shock by jumping. However the Dogs did not. Ie they developed a state of
learned Helplessness.
• Dog had learned that trying to escape from the shocks was useless.
• In depression helplessness and hopelessness was suggested to happen.