Mood Disorder NOS, How I make the Diagnosis-Q and A
Why make the diagnosis of Mood Disorder NOS?
I do this so I don't over or under diagnosis, and thus not over or under treat the problem, yet preserving diagnoistic accuracy, without prematurely and unfairly giving a patient a diagnosis that is not accurate, and possibly having a prognosis either too severe or too mild for their presentation.
Can you be more specific about what you mean?
I make this diagnosis when symptoms of an unstable mood disorder are present especially irritability, anger and rage, and one or two others, yet not enough symptoms to fit the specific criteria of Unipolar Depression or a specific Bipolar sub type of unstable mood, as is further described below. Too many people are over diagnosed with Bipolar and yet don't fit the picture, and many many more are grossly misdiagnosed has having a classical Unipolar Depression, and this is often an under diagnosis not reflecting the underlying brain chemistry driving the mood symptoms. These errors in diagnosis result in over medication of the first group with using multiple mood stabiliziers and lithium, and mis-use of antidepressants for the second group which is not only a case of under medicating but may actually inflame the process and can lead to psychosis, mania and increase of suicidal and outwardly destructive behaviors. The diagnosis of Mood Disorder NOS more appropriately fits some of these patients, and the use of mood stabilizing medication, but not to the extent one would use with true Bipolar is the more appropriate medication choice. Read on to understand how I make the diagnosis and choose the appropriate treatment.
My child is mostly presenting with irritability, anger and rage, why are you calling this Mood Disorder NOS?
Irritability, anger and rage [IAR] if it the major presenting problem may be caused by one or many diagnoses. IrritabilityAngerRage When it best fits into the DSM category of a Mood Disorder, usually with an unstable pattern with similar brain chemistry, though not necessarily identical to Bipolar types, and yet does not meet the specific criterion for Bipolar or Unipolar episodes, then the more general category of Mood Disorder NOS [Not Otherwise Specified] is used. Though IAR is often the presenting or most severe symptom other signs and symptoms of a mood disorder, such as problems with being distractible, hyperactivity, being impulsive, that is not thinking before acting, getting insufficient sleep, talking so fast people have trouble following him, and being overly involved with pleasurable activities. At least a few of these symptoms [ 5 for the depression, and 4 for the excitable phase] must also be present before one would make the diagnosis of any specific mood disorder.
You mentioned in the above list of symptoms Hyperactivity, Impulsivity, and Distractibility[HID], aren’t those the core symptoms of ADHD, why doesn’t this child have this Diagnosis, I was told for years that was part of the problem?
This child may or may not also have ADHD. The core symptoms alone don’t make a diagnosis, but also other criteria must be met. For example in the DSM it clearly states don’t diagnosis ADHD if the core symptoms of HID[ ADHDtheDiagnosis ]occur during the course of another disorder or is better explained by another disorder. In the above example the child has mood disturbance with possibly 7 our 7 possible core symptoms of an excitable or manic episode, which meets the criteria for a specific Bipolar subtype, or perhaps more generally Mood Disorder NOS might be more appropriate.
How would one know if there is a second diagnosis of ADHD?
If other factors such as lack of response to medication treatment of the HID, when the mood disorder is treated, and developmental and family history, especially if positive for ADHD may mean it is present as a second diagnosis and may need its own specific medication treatment. ADHD-Stimulant Medications-Intro Q and A, ADHD Fact Sheet Though this is an important thing to to be able to tell the various diagnoses apart especially when they have the same or similar symptoms, but for now let us get back to trying to make sense out of the various presentations of mood disorders.
I was also lead to believe that most of my child’s problems were caused by ODD or Oppositional Defiant Disorder, could he have that too?
First you need to understand the DSM diagnosis of ODD is descriptive and by design does not imply any causation, biological or non biological. Again don’t confuse descriptive symptoms with biological based syndromes that have specific brain chemistry as a causation. This child’s ODD like his ADHD may be better explained by a mood problem which may have a specific biochemical basis, or it may be a separate diagnosis which I will address after we go over more information about the specific types of mood disorders.ODD,ADHD or Mood
What are the specifics of making the diagnosis of Unipolar vs. Bipolar vs. Mood Disorder NOS , that present with IAR?
A mood disorder could be either Unipolar usually having a stable mood, or Bipolar which usually has an unpredictably unstable mood. Unipolar Disorders are Low Energy with Loss of interest having a stable symptom complex present with mostly downs or low energy, and Bipolar is an Excitable mood with High Energy and is unstable may have initially only high energy states, but usually if you look closely enough or wait for the disorder to evolve over time or substantiated by developmental of family history, it will show the two poles, of high and low energy. If the presentation of mood symptoms doesn’t fit specifically into either the Unipolar, or Bipolar type or one in not sure, there is the more general, less specific category of Mood Disorder NOS, or Not Otherwise Specified. The way IAR can present in these various spectrums differs, usually have different brain chemistry, and thus has different medication approaches.
Can you tell me more about these mood spectrums and how they present differently with IAR?
Mood disorders are divided into two basic types of states or episodes, Depressive Episodes or Manic Episodes and called Mixed , if both episodes present. People with only Depressive Episodes, that is in the Unipolar Spectrum, tend to have stable moods, that is not having severe ups and downs or mood swings, are more predictable and easy to live, and if they get IAR it is short lived and not too severe. People with Manic or Mixed episodes, fall into the Bipolar Spectrum, that is having features of Mania alone, just the high energy excitable phase, or show clearly two poles, thus called Bipolar, having ups and downs. They have severe and frequent , and often unpredictable mood swings[Dr Jeckle and Mr. Hyde] especially when their grandiosity [ have abnormally elevated sense of self importance] is threatened [ like being told what to do] or questioned[told that they are wrong, or can’t have what they want]. Bipolar types are also very difficult to live with[“walking on egg shells”]. As you see these are two very different presentations with very different responses from the environment.
Why is it important to know what kind of episode is causing the IAR?
The most important reason is that the treatments are very different, based on underlying brain chemistry problems. Medicine for Unipolar Stable Depressive Episodes can make Bipolar Unstable Episodes whether they are primarily depressed or excitable markedly worse, often after a brief period of what seemed like reassuring improvement. Most Mood Disorders NOS are unstable and should be treated like it has brain chemistry similar to the Bipolar Spectrum.AntiDepressantWorsenSymptoms, Depression which is it, Unipolar or the unstable Bipolar type, Q and A
How can one best determine if the cause of IAR is due to unstable brain chemistry so the right medications are used?
History, history and more history, and perhaps a carefully done medication trial. Get history about all of the symptoms, their course since infancy, family history of symptoms and their course and treatment response, and history about any medication used what the response was to it. The key symptoms or problems to screen for are those of a Manic Episode in all of their possible manifestations, including their depressive flip side presentation, which may be very brief, showing itself with only a loss of interest features or physical problems like migraine headache and irritable bowel.
What are the cardinal symptoms of Mania or the Excitable type episode, and what do you mean by their manifestations and flip side presentation that need to be looked for?
Use the memory aid DIG FAST to remember these 7 clusters of symptoms of the high energy state: Distractibility, Insomnia, Grandiosity, Flight of ideas, increase of goal directed Activities, Speech that is excessive, Thoughtlessness characterized by being driven and involved in self-centered impulsive pleasurable activities that have a high potential for painful consequences. The eight symptoms of the flip side or the low energy Depressive spectrum can be represented by the memory aid SIG E CAPS, standing for problems with Sleep, decrease Interest in life, negative outlook and Guilt, Energy, drive and motivation problems mostly decreased, Concentration problems, Appetite and other physical problems, like headaches, bowel problems, negative thinking, hopelessness and Suicidal thinking.
Below are these symptoms or problems side by side for comparison purposes. I go over these in greater detail elsewhere.Bipolar and Unstable Mood Disorders, Suicide, What to Know and What to do. Q and A
Depressed-Low Energy Episode Manic-Excitable-High Energy Episode
Mood: Depressed, irritable or loss of interest Excitable, high energy, irritable, angry, rageful
Concentration: poor due to slow thinking Distractible due to thinking too fast and too much
Sleep: tired, too much sleep, feeling not rested Insomnia, getting very little sleep, but feels rested
Self Image: negative, hopeless, suicidal thinking Grandiose –elevated sense of self, optimistic
Thinking: is slow, hard to think Flight of ideas or sense of thinking fast
Energy level: even when rested feels tired Activity level-Energy is high most of the time
Speech-like thinking may be slow, hesitant Speech-is significantly more talkative
Impulsivity usually not present but over thinks Thoughtless and impulsive
What turns symptoms or an episode of Excitability or Mania or Depression or Irritability or “loss of interest” into a disorder requiring further evaluation and treatment?
First to make a specific diagnosis there must be a specific duration of the problem. There must be a least a week [for Bipolar]or two weeks [for Unipolar] of symptoms, secondly there must be more than one or two symptoms, at least 5 for the depressed phase, and 4 symptoms if in the excitable phase, leading to impairment and distress that is significant. Only when there is significant impairment in functioning or distress for a specific length of time would one qualify for a diagnosis or having a mood disorder. This means someone has mood problem that is of such severity that it is causing problems in functioning at home, work, school, socially, in relationships, or causing the person much distress, that is pain and suffering, either with mental health or physical symptoms. If one has some of the symptoms but not the required number or if the duration is less than a week or two, or if you are not sure then would be appropriate to use a more general diagnosis like Mood Disorder NOS, rather than the more specific Bipolar or Unipolar diagnostic options.
Sometimes the symptoms are present , and sometimes not, why is this?
By definition the symptoms of an unstable mood problem come and go, that is they occur in cycles or episodes. The cycles could be years, months, days or even hours. The younger you are the more likely the cycles will be frequent, not unusually occurring in hours, this being called ultra rapid cycling. Though the most dramatic symptoms may occur only when grandiosity is questioned or threatened, if one looks carefully and takes a complete history, one can find less dramatic cycles of alternating high and low energy, with the expected symptoms which are not even thought of as symptoms because they are relatively less of a problem when compared to IAR.
What would be some examples of these less dramatic symptoms and problems?
The person who has changes in their ability to concentrate that effects their productivity at home, work or school. It could be changing sleep patterns, sleeping too much, too little, waking up to eat, hard to wake up, again happening on and off in episodes. Mild or subtle mood changes not considered depression yet representing the low energy phase, a general lack of interest in things, and I don’t care attitude, too easily bored, everything is boring , nothing is fun right now, don’t feel like doing anything. Changing feeling about one self worth alternating between thinking either too highly or too poorly about one’s self, ones work , and relationships. Short periods of feeling slowed down because one doesn’t feel well, I am sick, or actual physical syndromes that force you to slow down are really the low energy equivalents of depression and the down part of a cycle. Headaches, Stomach-Bowel-other Physical Problems caused by Brain Chemistry of MH disorders Periods of mental exhaustion after days or weeks of high energy mental productiveness, may indicated a low energy state. Anything that has an upside has down side, and if it comes and goes in cycles and is correlated by changes in mood may be representative of unstable mood cycles especially if excessive and periodically persistent. Look for a pattern, map it out on a calendar.
What are the other disorders or diagnoses that should be ruled out before concluding it is Mood causing IAR?
First rule out any medical causes, like seizures, or thyroid illness just to name two. Next be sure there are no substances like prescribed or over the counter medications, abuse -able drugs and alcohol that might be contributing or causing the IAR. Any mental health or psychiatric syndrome including delirium and dementia,How a Psychiatric Medical Doctor starts to make a Diagnosis Q and A, Initial Screen with Example Diagnosis and Medication Responsiveness may first present with IAR, but the most likely ones that that need to be considered and ruled out are psychotic thinking disorders like Schizophrenia, Tourette’s type disorders, any Anxiety disorder, on the bottom of the list should be ADHD. Special mention needs to made for the person with ODD or Oppositional Defiant Disorder or traits and the person who fits into none of the usual categories and has Atypical Brain Chemistry.
Could there be more than one diagnosis present and thus a need for multiple medication types?
Yes this is highly possible and requires someone with the expertise and time to tease apart the various symptoms, and try to make sense of what diagnosis may be causing them and what the underlying biochemical diagnosis may be. This is the art and science of what we call differential diagnosis in medicine and is discussed in depth elsewhere and when specific disorders are covered. I have already briefly mentioned the diagnosis of ADHD, and below I will do the same for ODD and the “Atypical” situations.
What about this diagnosis of ODD?
As I said above this is a descriptive diagnosis with no implication of any specific brain chemistry problem. If it is caused by learned behavior, then a behavioral program using rewards and consequences will help. If caused by emotional conflict then traditional counseling and psychotherapy may help. However any mental health disorder with a biological basis like ADHD or a Mood problem may present with ODD. Usually when you treat the underlying brain chemistry the ODD gets better. I have seen children and adolescents in treatment for years for ODD that doesn’t get better because a biological cause is not recognized and thus never treated. Also because of this the underlying disorder is never recognized, treated , likely gets worse and may develop complications, like anxiety states, drug and alcohol problems, worsening of physical symptoms like headaches and irritable bowel just to name two. Also academic, work and relationship failures due to intolerable behaviors due to unstable moods are common complications.
What is this “Atypical Brain” chemistry issue?
This could mean one of two things. First there are people who meet the usual criterion but no matter how hard you try to adjust medication they have unpredictable and poor responses, and other medications or way of prescribing them must be tried. These people have “atypical” medication responses. There is a group of people who really don’t easily fit into any usual diagnositic category even the residual NOS category, and yet have significant symptoms from many diagnositic groups, and these symptoms may come and go, and change more than is expected based on normal development and the course of an episodic disorder. These people children, teens and adults are truly “Atypical” people base on their symptom presentation and often in their responses to usual medications in the usual doses, perhaps having their own diagnostic category which I have postulated.The Atypical Child-Person a proposed special diagnositic entity.