Mood Disorder Due to a General Medical Condition

Mood disorder due to a general medical condition, also known as a secondary mood disorder, is a critical consideration in assessing mood symptoms in a physically ill patient (see Table 6-7). The diagnosis of secondary depression or mania requires the presence of prominent, persistent, distressing, or functionally impairing depression and/or elevated, expansive, or irritable mood that is thought to be the result of a physical condition and/or its treatment (e.g., medications). The type of mood episode— manic or depressive—and whether these symptoms meet the threshold for the disorder must be specified. The lists of general medical conditions that may present with mood symptoms (see Table 6-8) and medications that may be associated with mood symptoms (see Table 6-9) are long.

The distinction between primary and secondary mood disorders is often based on a temporal relationship between the onset of a physical illness and the onset of mood symptoms. The symptoms of secondary mood disorders are similar to those of primary mood disorders, although in the former the presence of cognitive impairments with the depressive or manic symptoms is uncommon. Although the prevalence and course of these disorders are unknown, evidence indicates that secondary mood disorders have a poorer prognosis than primary mood disorders because the secondary mood disorders are primarily related to continuous, remitting,

Table 6-7. DSM-IV-TR diagnostic criteria for mood disorder due to a general medical condition

A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following:

(1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities

(2) elevated, expansive, or irritable mood

B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.

C. The disturbance is not better accounted for by another mental disorder (e.g., adjustment disorder with depressed mood in response to the stress of having a general medical condition).

D. The disturbance does not occur exclusively during the course of a delirium.

E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify type:

With Depressive Features: if the predominant mood is depressed but the full criteria are not met for a major depressive episode

With Major Depressive-Like Episode: if the full criteria are met (except Criterion D) for a major depressive episode

With Manic Features: if the predominant mood is elevated, euphoric, or irritable

With Mixed Features: if the symptoms of both mania and depression are present but neither predominates

Coding note: Include the name of the general medical condition on Axis I, e.g., 293.83 Mood Disorder Due to Hypothyroidism, With Depressive Features; also code the general medical condition on Axis III.

Coding note: If depressive symptoms occur as part of a preexisting vascular dementia, indicate the depressive symptoms by coding the appropriate subtype, i.e., 290.43 vascular dementia, with depressed mood.

or relapsing courses of physical illnesses (American Psychiatric Association 1994).

The associations between the presence of depression and physical illnesses have been a focus of much investigation among adults. Depression is present in almost all physical illnesses in which the connection has been studied, including cardiac disease, certain neurological disorders, epilepsy, diabetes, cancer, AIDS, and chronic pain syndromes (Evans et al. 2005a). Significant confounding overlaps between DSM-IV-TR symptoms of depression and symptoms of physical illness and/or its treatment must be considered (see Table 6-10).

Less is known about secondary mania. Potential predisposing factors for its development include a personal or family history of an affective disorder or bipolar disorder (Jorge et al. 1993). Furthermore, making the diagnosis may be more complicated in a patient with preexisting manic illness or vulnerability to manic illness. Secondary mania can sometimes present as inattention, agitation, poor sleep, and psychosis, resembling delirium. The onset can occur within hours to days of an organic insult and can be difficult to distinguish from delirium. The diagnosis of secondary mania is more likely if the patient has no prior history or family history of manic illness, has focal neurological findings or cognitive dysfunction, and has mood symptoms that have been poorly responsive to treatments (Jorge et al. 1993).

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