DSM–5

View and Comment on Recently Proposed Changes to DSM–5

The following proposal was approved by the DSM Steering Committee and is being posted for a 30-day public comment period.

Comment Period Opens: April 1, 2019

Comment Period Closes: April 30, 2019

Comment on Proposal

Proposal: Restoration of an Unspecified Mood Disorder Category in DSM-5

Issue

APA received a question from a large healthcare organization asking what DSM-5 diagnosis would apply to "a patient with mood symptoms, possibly including depressive and manic symptoms, which the clinician feels cannot be easily categorized as a bipolar or depressive syndrome." Although such patients would have been diagnosed with Mood Disorder NOS in DSM-IV, that diagnosis is not available in DSM-5. The only "unspecified" diagnoses available in DSM-5 for unspecified mood symptoms are Unspecified Bipolar Disorder or Unspecified Depressive Disorder, essentially forcing the clinician to pick between these two diagnoses for mixed cases. The problem with simply putting down Unspecified Bipolar Disorder is that this diagnoses mischaracterizes the presentation as being clearly part of the bipolar spectrum when in fact whether it is best thought of as a depressive disorder with mixed features or rather a bipolar disorder with mixed features is unknown at this point in the evaluation process but might become more apparent as additional diagnostic information comes to light with the passage of time. Moreover, making a diagnosis of unspecified bipolar disorder before there is solid evidence that the presentation is part of the bipolar spectrum has the potential to result in unjustified stigmatization as well as a potential negative impact on future insurability. Hence, the appropriateness of having available an unspecified mood disorder diagnosis, which was defined on page 410 in DSM-IV-TR as follows: "this category includes disorders with mood symptoms that do not meet the criteria for any specific Mood Disorder and in which it is difficult to choose between Depressive Disorder NOS and Bipolar Disorder NOS (e.g., acute agitation)."

The removal of Unspecified Mood Disorder from DSM-5 was an unintentional byproduct of the DSM-5 decision to eliminate the Mood Disorders diagnostic class from DSM-5 in favor of making Bipolar Disorders and Depressive Disorders top-level diagnostic classes (i.e., at the same level as Neurodevelopmental Disorder, Anxiety Disorders, etc.). Consequently, the Mood Disorder NOS category also had to be eliminated in keeping with the DSM and ICD convention that the unspecified categories are by necessity linked to a diagnostic class, given that they are defined as applying to presentations that do not meet criteria for any specific disorder in that diagnostic class.

As was noted in the proposal, the workaround in the healthcare organization's facilities is to use the ICD-10-CM category "Unspecified Mood Disorder" which has a diagnostic code of F39, a diagnostic "code that is currently a part of our Masterfile of diagnoses with the label of 'Mood Disorder.'" It has a lot of use across this particular system and clinicians do not want to part with it. They see it as a term to use when they remain uncertain whether the patient has a primarily bipolar or depressive syndrome.

In response to a request by the DSM Steering Committee for data that might shed some light on the clinical significance of the problem, the healthcare organization provided data on the use of unspecified depressive disorder, unspecified bipolar disorder, and unspecified mood disorder in office visit encounters with a date of service the period extending from January 1, 2018 through October 30, 2018. The usage data indicated the following: The Depression NOS (F32.9) code was used 112,370 times (compared to a usage of 563,097 for Major Depressive Disorder, single episode or recurrent), the Bipolar NOS codes (F31,89 and F31.9) were used 74,554 times (compared to a usage of 45,040 for one of the specific bipolar codes), and Unspecified Mood Disorder (F38) was used 28,133 times. While usage of Unspecified Mood Disorder represented only a small fraction (15%) of the overall usage of the unspecified codes, the usage of this code is surprisingly high given that Unspecified Mood Disorder does not appear as a sanctioned category in DSM-5.

It is thus being proposed that "Unspecified Mood Disorder" be restored to DSM-5 (to apply to presentations that do not meet the criteria for any specific mood disorder and in which it is difficult to choose between an Unspecified Depressive Disorder and an Unspecified Bipolar Disorder (e.g., acute agitation). Given the absence of a Mood Disorders grouping in DSM-5, Unspecified Mood Disorder would be located within both the Depressive Disorders chapter as well as the Bipolar Disorders chapter. Doing so would make DSM-5 more compatible with both ICD-10-CM (which as noted above includes the category) as well as ICD-11, which also includes this category. It will also provide clinicians with a more accurate and less stigma-prone diagnosis for these kinds of mixed presentations.

The Fixes

DSM-5 Classification p. xvii:

Bipolar Disorder

  • ___.__ (___.__)     Bipolar I Disorder (123)
  • ___.__ (___.__)     Current or most recent episode manic
  • ___.__ (___.__)     Current or most recent episode depressed
  • 296.7 (F31.9)     Current or most recent episode unspecified
  • 296.89 (F31.81)     Bipolar II Disorder (132)
  • 301.13 (F34.0)     Cyclothymic Disorder (139)
  • 293.83 (___.__)     Bipolar and Related Disorder Due to Another Medical Condition (145)
  • 296.89 (F31.89)     Other Specified Bipolar and Related Disorder (148)
  • 296.80 (F31.9)     Unspecified Bipolar and Related Disorder (149)
  • 296.90 (F39)     Unspecified Mood Disorder

DSM-5 Classification p. xviii:

Depressive Disorder

  • 296.99 (F34.8)     Disruptive Mood Dysregulation Disorder (156)
  • ___.__ (___.__)     Major Depressive Disordera (160)
  • ___.__ (___.__)     Single episode
  • ___.__ (___.__)     Recurrent episode
  • 300.4 (F34.1)     Persistent Depressive Disorder (Dysthymia)a (168)
  • 625.4 (N94.3)     Premenstrual Dysphoric Disorder (171)
  • 293.83 (___.__)     Depressive Disorder Due to Another Medical Condition (180)
  • 311 (F32.8)     Other Specified Depressive Disorder (183)
  • 311 (F32.9)     Unspecified Depressive Disorder (184)
  • 296.90 (F39)     Unspecified Mood Disorder

DSM-5 p. 149 and 184:

F39 Unspecified Mood Disorder

This category applies to presentations in which symptoms characteristic of a mood disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not at the time of the evaluation meet the full criteria for any of the disorders in either the bipolar or depressive disorders diagnostic classes and in which it is difficult to choose between Unspecified Bipolar Disorder and Unspecified Depressive Disorder (e.g., acute agitation).

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