Mood disorder due to a general medical condition

293.83 Mood Disorder Due to a General Medical Condition

Diagnostic Features

The essential feature of Mood Disorder Due to a General Medical Condition is a prominent and persistent disturbance in mood that is judged to be due to the direct physiological effects of a general medical condition. The mood disturbance may involve depressed mood; markedly diminished interest or pleasure; or elevated, expansive, or irritable mood (Criterion A). Although the clinical presentation of the mood disturbance may resemble that of a Major Depressive, Manic, Mixed, or Hypomanic Episode, the full criteria for one of these episodes need not be met; the predominant symptom type may be indicated by using one of the following subtypes: With Depressive Features, With Major Depressive-Like Episode, With Manic Features, or With Mixed Features. There must be evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition (Criterion B). The mood disturbance is not better accounted for by another mental disorder (e.g., Adjustment Disorder With Depressed Mood that occurs in response to the psychosocial stress of having the general medical condition) (Criterion C). The diagnosis is also not made if the mood disturbance occurs only during the course of a delirium (Criterion D). The mood disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion E). In some cases, the individual may still be able to function, but only with markedly increased effort.

In determining whether the mood disturbance is due to a general medical condition, the clinician must first establish the presence of a general medical condition. Further, the clinician must establish that the mood disturbance is etiologically related to the general medical condition through a physiological mechanism. A careful and comprehensive assessment of multiple factors is necessary to make this judgment. Although there are no infallible guidelines for determining whether the relationship between the mood disturbance and the general medical condition is etiological, several considerations provide some guidance in this area. One consideration is the presence of a temporal association between the onset, exacerbation, or remission of the general medical condition and that of the mood disturbance. A second consideration is the presence of features that are atypical of primary Mood Disorders (e.g., atypical age at onset or course or absence of family history). Evidence from the literature that suggests that there can be a direct association between the general medical condition in question and the development of mood symptoms can provide a useful context in the assessment of a particular situation. In addition, the clinician must also judge that the disturbance is not better accounted for by a primary Mood Disorder, a Substance-Induced Mood Disorder, or other primary mental disorders (e.g., Adjustment Disorder). This determination is explained in greater detail in the "Mental Disorders Due to a General Medical Condition" section (p. 181).

In contrast to Major Depressive Disorder, Mood Disorder Due to a General Medical Condition, With Depressive Features, appears to be nearly equally distributed by gender. Mood Disorder Due to a General Medical Condition increases the risk of attempted and completed suicide. Rates of suicide are variable depending on the particular general medical condition, with chronic, incurable, and painful conditions (e.g., malignancy, spinal cord injury, peptic ulcer disease, Huntington's disease, acquired immunodeficiency syndrome [AIDS], end-stage renal disease, head injury) carrying the greatest risk for suicide.

Subtypes

One of the following subtypes may be used to indicate which of the following symptom presentations predominates:

With Depressive Features. This subtype is used if the predominant mood is depressed, but the full criteria for a Major Depressive Episode are not met.
With Major Depressive-Like Episode. This subtype is used if the full criteria (except Criterion D) for a Major Depressive Episode (see p. 356) are met.
With Manic Features. This subtype is used if the predominant mood is elevated, euphoric, or irritable.
With Mixed Features. This subtype is used if the symptoms of both mania and depression are present but neither predominates.

Recording Procedures

In recording the diagnosis of Mood Disorder Due to a General Medical Condition, the clinician should note both the specific phenomenology of the disturbance, including the appropriate subtype, and the identified general medical condition judged to be causing the disturbance on Axis I (e.g., 293.83 Mood Disorder Due to Thyrotoxicosis, With Manic Features). The ICD-9-CM code for the general medical condition should also be noted on Axis III (e.g., 242.9 thyrotoxicosis). (See Appendix G for a list of selected ICD-9-CM diagnostic codes for general medical conditions.)

A separate diagnosis of Mood Disorder Due to a General Medical Condition is not given if the depressive symptoms develop exclusively during the course of Vascular Dementia. In this case, the depressive symptoms are indicated by specifying the subtype With Depressed Mood (i.e., 290.43 Vascular Dementia, With Depressed Mood).

Associated General Medical Conditions

A variety of general medical conditions may cause mood symptoms. These conditions include degenerative neurological conditions (e.g., Parkinson's disease, Huntington's disease), cerebrovascular disease (e.g., stroke), metabolic conditions (e.g., vitamin B12 deficiency), endocrine conditions (e.g., hyper- and hypothyroidism, hyper- and hypoparathyroidism, hyper- and hypoadrenocorticism), autoimmune conditions (e.g., systemic lupus erythematosus), viral or other infections (e.g., hepatitis, mononucleosis, human immunodeficiency virus [HIV]), and certain cancers (e.g., carcinoma of the pancreas). The associated physical examination findings, laboratory findings, and patterns of prevalence or onset reflect the etiological general medical condition.

Prevalence

Prevalence estimates for Mood Disorder Due to a General Medical Condition are confined to those presentations with depressive features. It has been observed that 25%-40% of individuals with certain neurological conditions (including Parkinson's disease, Huntington's disease, multiple sclerosis, stroke, and Alzheimer's disease) will develop a marked depressive disturbance at some point during the course of the illness. For general medical conditions without direct central nervous system involvement, rates are far more variable, ranging from more than 60% in Cushing's syndrome to less than 8% in end-stage renal disease.

Differential Diagnosis

A separate diagnosis of Mood Disorder Due to a General Medical Condition is not given if the mood disturbance occurs exclusively during the course of a delirium. In contrast, a diagnosis of Mood Disorder Due to a General Medical Condition may be given in addition to a diagnosis of dementia if the mood symptoms are a direct etiological consequence of the pathological process causing the dementia and if the mood symptoms are a prominent part of the clinical presentation (e.g., Mood Disorder Due to Alzheimer's Disease). Because of ICD-9-CM coding requirements, an exception to this is when depressive symptoms occur exclusively during the course of Vascular Dementia. In this case, only a diagnosis of Vascular Dementia with the subtype With Depressed Mood is given; a separate diagnosis of Mood Disorder Due to a General Medical Condition is not made. If the presentation includes a mix of different types of symptoms (e.g., mood and anxiety), the specific mental disorder due to a general medical condition depends on which symptoms predominate in the clinical picture.

If there is evidence of recent or prolonged substance use (including medications with psychoactive effects), withdrawal from a substance, or exposure to a toxin, a Substance-Induced Mood Disorder should be considered. It may be useful to obtain a urine or blood drug screen or other appropriate laboratory evaluation. Symptoms that occur during or shortly after (i.e., within 4 weeks of) Substance Intoxication or Withdrawal or after medication use may be especially indicative of a Substance-Induced Disorder, depending on the character, duration, or amount of the substance used. If the clinician has ascertained that the disturbance is due to both a general medical condition and substance use, both diagnoses (i.e., Mood Disorder Due to a General Medical Condition and Substance-Induced Mood Disorder) are given.

Mood Disorder Due to a General Medical Condition must be distinguished from Major Depressive Disorder, Bipolar I Disorder, Bipolar II Disorder, and Adjustment Disorder With Depressed Mood (e.g., a maladaptive response to the stress of having a general medical condition). In Major Depressive, Bipolar, and Adjustment Disorders, no specific and direct causative physiological mechanisms associated with a general medical condition can be demonstrated. It is often difficult to determine whether certain symptoms (e.g., weight loss, insomnia, fatigue) represent a mood disturbance or are a direct manifestation of a general medical condition (e.g., cancer, stroke, myocardial infarction, diabetes). Such symptoms count toward a diagnosis of a Major Depressive Episode except in cases where they are clearly and fully accounted for by a general medical condition. If the clinician cannot determine whether the mood disturbance is primary, substance induced, or due to a general medical condition, Mood Disorder Not Otherwise Specified may be diagnosed.

Diagnostic criteria for 293.83 Mood Disorder Due to . . .[Indicate the General Medical Condition]

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
There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
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).
The disturbance does not occur exclusively during the course of a delirium.
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 (see p. 356)
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

Diagnostic criteria for 293.83 Mood Disorder Due to . . .
[Indicate the General Medical Condition] (continued)

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 (see Appendix G for codes).
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.