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`Exhibit 2019
`Slayback v. Sumitomo
`IPR2020-01053
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`
`DIAGNOSTIC AND STATISTICAL
`
`MANUAL OF
`
`MENTAL DISORDERS
`
`FOURTH EDITION
`
`DSM-IVTM
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`DIAGNOSTIC AND STATISTICAL
`
`MANUAL OF
`
`MENTAL DISORDERS
`
`FOURTH EDITION
`
`DSM—IVTM
`
`
`
`PUBLISHED BY THE
`
`AMERICAN PSYCHIATRIC ASSOCIATION
`
`WASHINGTON, DC
`
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`Copyright © 1994 American Psychiatric Association
`
`ALL RIGHTS RESERVED. Unless authorized in writing by the APA, no part of this book may be
`reproduced or used in a manner inconsistent with the APA’s copyright. This prohibition applies
`to unauthorized uses or reproductions in any form, including electronic applications.
`
`Manufactured in the United States of America on acid-free paper
`
`American Psychiatric Association
`1400 K Street, N .W., Washington, DC 20005
`
`Correspondence regarding copyright permissions should be directed to the Division of Publica—
`tions and Marketing, American Psychiatric Association, 1400 K Street, N.W., Washington, DC
`20005.
`
`DSM and DSM—lV are trademarks of the American Psychiatric Association. Use of these terms is
`prohibited without permission of the American Psychiatric Association.
`
`The correct citation for this book is American Psychiatric Association: Diagnostic and Statistical
`Manual ofMental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association,
`1994.
`
`Library of Congress Cataloging-in-Publication Data
`Diagnostic and statistical manual of mental disorders : DSM-IV. — 4th ed.
`p.
`cm.
`Prepared by the Task Force on DSM—IV and other committees and work
`groups of the American Psychiatric Association.
`Includes index.
`
`ISBN 0-89042—061-0 (hard : alk. paper). — ISBN 0-89042-062-9 (paper : alk. paper)
`1. Mental illness—Classification.
`2. Mental illness—Diagnosis.
`1. American Psychiatric Association.
`11. American Psychiatric
`Association. Task Force on DSM-IV.
`111. Title: DSM—I'V.
`[DNLM:
`1. Mental Disorders—classification.
`2. Mental Disorders—
`
`diagnosis. WM 15 D536 1994]
`RC455.2.C4D54
`1994
`616.89’075—dc20
`DNLM/DLC
`
`for Library of Congress
`
`British Library Cataloguing in Publication Data
`A CIP record is available from the British Library.
`
`First printing 150,000, May 1994
`
`Text Design—jane H. Davenport
`Manufacturing-—-R. R. Donnelly & Sons Company
`
`94—6504
`CIP
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`350 Mood Disorders
`
`3] l Depressive Disorder Not Otherwise Specified
`
`The Depressive Disorder Not Otherwise Specified category includes disorders with
`depressive features that do not meet
`the criteria for Major Depressive Disorder,
`Dysthymic Disorder, Adjustment Disorder With Depressed Mood (see p. 625), or
`Adjustment Disorder With Mixed Anxiety and Depressed Mood (see p. 624). Sometimes
`depressive symptoms can present as part of an Anxiety Disorder Not Otherwise Specified
`(see p. 444). Examples of Depressive Disorder Not Otherwise Specified include
`
`1. Premenstrual dysphoric disorder: in most menstrual cycles during the past year,
`symptoms (eg, markedly depressed mood, marked anxiety, marked affective
`lability, decreased interest in activities) regularly occurred during the last week
`of the luteal phase (and remitted within a few days of the onset of menses).
`These symptoms must be severe enough to markedly interfere with work, school,
`or usual activities and be entirely absent for at least 1 week postmenses (see
`p. 715 for suggested research criteria).
`2. Minor depressive disorder: episodes of at least 2 weeks of depressive symptoms
`but with fewer than the five items required for Major Depressive Disorder (see
`p. 719 for suggested research criteria).
`3. Recurrent brief depressive disorder: depressive episodes lasting from 2 days up
`to 2 weeks, occurring at least once a month for 12 months (not associated with
`the menstrual cycle) (see p. 721 for suggested research criteria).
`4. Postpsychotic depressive disorder of Schizophrenia: a Major Depressive Episode
`that occurs during the residual phase of Schizophrenia (see p. 711 for suggested
`research criteria).
`
`5. A Major Depressive Episode superimposed on Delusional Disorder, Psychotic
`Disorder Not Otherwise Specified, or the active phase of Schizophrenia.
`6. Situations in which the clinician has concluded that a depressive disorder is
`present but is unable to determine Whether it is primary, due to a general medical
`condition, or substance induced.
`
`dipoles Disorders
`
`This section includes Bipolar I Disorder, Bipolar II Disorder, Cyclothymia, and Bipolar
`Disorder Not Otherwise Specified. There are six separate criteria sets for Bipolar I
`Disorder: Single Manic Episode, Most Recent Episode Hypomanic, Most Recent Episode
`Manic, Most Recent Episode Mixed, Most Recent Episode Depressed, and Most Recent
`Episode Unspecified. Bipolar I Disorder, Single Manic Episode,
`is used to describe
`individuals who are having a first episode of mania. The remaining criteria sets are used
`to specify the nature of the current (or most recent) episode in individuals who have
`had recurrent mood episodes.
`
`Bipolar I Disorder
`
`Diagnostic Features
`
`The essential feature of Bipolar I Disorder is a clinical course that is characterized by
`the occurrence of one or more Manic Episodes (see p. 328) or Mixed Episodes (see
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`Bipolar I Disorder
`351
`
`p. 333). Often individuals have also had one or more Major Depressive Episodes (see
`p. 320). Episodes of Substance-Induced Mood Disorder (due to the direct effects of a
`medication, other somatic treatments for depression, a drug of abuse, or toxin exposure)
`or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis
`of Bipolar I Disorder.
`in addition,
`the episodes are not better accounted for by
`Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform
`Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. Bipolar
`I Disorder is subclassified in the fourth digit of the code according to whether the
`individual is experiencing a first episode (i.e., Single Manic Episode) or whether the
`disorder is recurrent. Recurrence is indicated by either a shift in the polarity of the episode
`or an interval between episodes of at least 2 months without manic symptoms. A shift
`in polarity is defined as a clinical course in which a Major Depressive Episode evolves
`into a Manic Episode or a Mixed Episode or in which a Manic Episode or a Mixed Episode
`evolves into a Major Depressive Episode. In contrast, a Hypomanic Episode that evolves
`into a Manic Episode or a Mixed Episode, or a Manic Episode that evolves into a Mixed
`Episode (or vice versa), is considered to be only a single episode. For recurrent Bipolar
`I Disorders, the nature of the current (or most recent) episode can be specified (Most
`Recent Episode Hypomanic, Most Recent Episode Manic, Most Recent Episode Mixed,
`Most Recent Episode Depressed, Most Recent Episode Unspecified).
`
`Specifiers
`
`The following specifiers for Bipolar I Disorder can be used to describe the current Manic,
`Mixed, or Major Depressive Episode (or, if criteria are not currently met for a Manic,
`Mixed, or Major Depressive Episode, the most recent Manic, Mixed, or Major Depressive
`Episode):
`
`Mild, Moderate, Severe Without Psychotic Features, Severe With Psychotic
`Features, In Partial Remission, In Full Remission (see p. 376)
`With Catatonic Features (see p. 582)
`With Postpartum Onset (see p. 386)
`
`The following specifiers apply only to the current (or most recent) Major Depressive
`Episode only if it is the most recent type of mood episode:
`
`Chronic (see p. 382)
`With Melancholic Features (see p. 383)
`With Atypical Features (see p. 384)
`
`The following specifiers can be used to indicate the pattern of episodes:
`
`Longitudinal Course Specifier-s (With or Without Full Inter-episode
`Recovery) (see p. 387)
`With Seasonal Pattern (applies only to the pattern of Major Depressive
`Episodes) (see p. 589)
`With Rapid Cycling (see p. 590)
`
`Recording Procedures
`
`The diagnostic codes for Bipolar I Disorder are selected as follows:
`
`1. The first three digits are 296.
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`352 Mood Disorders
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`2. The fourth digit is 0 if there is a single Manic Episode. For recurrent episodes,
`the fourth digit is 4 if the current or most recent episode is a Hypomanic Episode
`or a Manic Episode, 6 if it is a Mixed Episode, 5 if it is a Major Depressive Episode,
`and 7 if the current or most recent episode is Unspecified.
`3. The fifth digit (except for Bipolar I Disorder, Most Recent Episode Hypomanic,
`and Bipolar I Disorder, Most Recent Episode Unspecified) indicates the follow-
`ing: 1 for Mild severity, 2 for Moderate severity, 3 for Severe Without Psychotic
`Features, 4 for Severe With Psychotic Features, 5 for In Partial Remission, 6 for
`In Full Remission, and 0 if Unspecified. Other specifiers for Bipolar I Disorder
`cannot be coded. For Bipolar I Disorder, Most Recent Episode Hypomanic, the
`fifth digit is always 0. For Bipolar Disorder, Most Recent Episode Unspecified,
`there is no fifth digit.
`
`In recording the name of a diagnosis, terms should be listed in the following order:
`Bipolar l Disorder, specifiers coded in the fourth digit (e.g., Most Recent Episode Manic),
`specifiers coded in the fifth digit (cg, Mild, Severe With Psychotic Features, In Partial
`Remission), as many specifiers (Without codes) as apply to the most recent episode (e.g.,
`With Melancholic Features, With Postpartum Onset), and as many specifiers (Without
`codes) as apply to the course of episodes (eg, With Rapid Cycling); for example, 296.54
`Bipolar I Disorder, Most Recent Episode Depressed, Severe With Psychotic Features,
`With Melancholic Features, With Rapid Cycling.
`Note that if the single episode of Bipolar l Disorder is a Mixed Episode, the diagnosis
`would be indicated as 296.0X Bipolar I Disorder, Single Manic Episode, Mixed.
`
`Associated Features and Disorders
`
`Associated descriptive features and mental disorders. Completed suicide occurs
`in 10%—15% of individuals with Bipolar I Disorder. Child abuse, spouse abuse, or other
`violent behavior may occur during severe Manic Episodes or during those with psychotic
`features. Other associated problems include school truancy, school failure, occupational
`failure, divorce, or episodic antisocial behavior. Other associated mental disorders
`include Anorexia Nervosa, Bulimia Nervosa, Attention—Deficit/Hyperactivity Disorder,
`Panic Disorder, Social Phobia, Substance—Related Disorders.
`
`Associated laboratory findings. There appear to be no laboratory features that
`distinguish Major Depressive Episodes found in Major Depressive Disorder from those
`in Bipolar l Disorder.
`
`Associated physical examination findings and general medical conditions.
`An age at onset for a first Manic Episode after age 40 years should alert the clinician to
`the possibility that the symptoms may be due to a general medical condition or substance
`use. There is some evidence that. untreated thyroid disease worsens the prognosis of
`Bipolar I Disorder.
`
`Specific Culture, Age, and Gender Features
`
`There are no reports of differential incidence of Bipolar I Disorder based on race or
`ethnicity. There is some evidence that clinicians may have a tendency to overdiagnose
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`Bipolar I Disorder
`
`353
`
`Schizophrenia (instead of Bipolar Disorder) in some ethnic groups and in younger
`individuals.
`
`Approximately 100/0—150/0 of adolescents with recurrent Major Depressive Episodes
`will go on to develop Bipolar I Disorder. Mixed Episodes appear to be more likely in
`adolescents and young adults than in older adults.
`Recent epidemiological studies in the United States indicate that Bipolar I Disorder
`is approximately equally common in men and women (unlike Major Depressive
`Disorder, which is more common in women). Gender appears to be related to the order
`of appearance of Manic and Major Depressive Episodes. The first episode in males is
`more likely to be a Manic Episode. The first episode in females is more likely to be a
`Major Depressive Episode. Women with Bipolar I Disorder have an increased risk of
`developing subsequent episodes (often psychotic) in the immediate postpartum period.
`Some women have their first episode during the postpartum period. The specifier With
`Postpartum Onset may be used to indicate that the onset of the episode is within 4 weeks
`of delivery (see p. 586). The premenstrual period may be associated with worsening of
`an ongoing Major Depressive, Manic, Mixed, or Hypomanic Episode.
`
`Prevalence
`
`The lifetime prevalence of Bipolar I Disorder in community samples has varied from
`0.4% to 1.6%.
`
`Course
`
`Bipolar I Disorder is a recurrent disorder—more than 90% of individuals who have a
`single Manic Episode go on to have future episodes. Roughly 60%—70% of Manic
`Episodes occur immediately before or after a Major Depressive Episode. Manic Episodes
`often precede or follow the Major Depressive Episodes in a characteristic pattern for a
`particular person. The number of lifetime episodes (both Manic and Major Depressive)
`tends to be higher for Bipolar I Disorder compared with Major Depressive Disorder,
`Recurrent. Studies of the course of Bipolar I Disorder prior to lithium maintenance
`treatment suggest that, on average, four episodes occur in 10 years. The interval between
`episodes tends to decrease as the individual ages. There is some evidence that changes
`in sleep—wake schedule such as occur during time zone changes or sleep deprivation
`may precipitate or exacerbate a Manic, Mixed, or Hypomanic Episode. Approximately
`5%—-15% of individuals with Bipolar I Disorder have multiple (four or more) mood
`episodes (Major Depressive, Manic, Mixed, or Hypomanic) that occur within a given
`year. If this pattern is present, it is noted by the specifier With Rapid Cycling (see p. 390).
`A rapid-cycling pattern is associated with a poorer prognosis.
`Although the majority of individuals with Bipolar I Disorder return to a fully
`functional level between episodes, some (200/0—300/0) continue to display mood lability
`and interpersonal or occupational difficulties. Psychotic symptoms may develop after
`days or weeks in what was previously a nonpsychotic Manic or Mixed Episode. When
`an individual has Manic Episodes with psychotic features, subsequent Manic Episodes
`are more likely to have psychotic features. Incomplete interepisode recovery is more
`common when the current episode is accompanied by mood—incongruent psychotic
`features.
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`354 Mood Disorders
`
`Familial Pattern
`
`First—degree biological relatives of individuals with Bipolar I Disorder have elevated rates
`of Bipolar I Disorder (4%—24%), Bipolar II Disorder (1%—5%), and Major Depressive
`Disorder (40/0—240/0). Twin and adoption studies provide strong evidence of a genetic
`influence for Bipolar I Disorder.
`
`Differential Diagnosis
`
`Major Depressive, Manic, Mixed, and Hypomanic Episodes in Bipolar I Disorder must
`be distinguished from episodes of a Mood Disorder Due to a General Medical
`Condition. The diagnosis is Mood Disorder Due to a General Medical Condition for
`episodes that are judged to be the direct physiological consequence of a specific general
`medical condition (e.g., multiple sclerosis, stroke, hypothyroidism) (see p. 366). This
`determination is based on the history, laboratory findings, or physical examination.
`A Substance-Induced Mood Disorder is distinguished from Major Depressive,
`Manic, or Mixed Episodes that occur in Bipolar I Disorder by the fact that a substance
`(e.g., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically
`related to the mood disturbance (see p. 570). Symptoms like those seen in a Manic,
`Mixed, or Hypomanic Episode may be part of an intoxication with or withdrawal from
`a drug of abuse and should be diagnosed as a Substance—Induced Mood Disorder (e. g.,
`euphoric mood that occurs only in the context of intoxication with cocaine would be
`diagnosed as Cocaine—Induced Mood Disorder, With Manic Features, With Onset During
`Intoxication). Symptoms like those seen in a Manic or Mixed Episode may also be
`precipitated by antidepressant treatment such as medication, electroconvulsive therapy,
`or light therapy. Such episodes may be diagnosed as a Substancevlnduced Mood Disorder
`(e.g., Amitriptyline-Induced Mood Disorder, With Manic Features; Electroconvulsive
`Therapy~1nduced Mood Disorder, With Manic Features) and would not count toward a
`diagnosis of Bipolar I Disorder. However, when the substance use or medication is
`judged not to fully account for the episode (e.g., the episode continues for a considerable
`period autonomously after the substance is discontinued), the episode would count
`toward a diagnosis of Bipolar I Disorder.
`Bipolar I Disorder is distinguished from Major Depressive Disorder and Dysthy—
`mic Disorder by the lifetime history of at least one Manic or Mixed Episode. Bipolar I
`Disorder is distinguished from Bipolar II Disorder by the presence of one or more
`Manic or Mixed Episodes. When an individual previously diagnosed With Bipolar II
`Disorder develops a Manic or Mixed Episode, the diagnosis is changed to Bipolar I
`Disorder.
`
`In Cyclothymic Disorder, there are numerous periods of hypomanic symptoms
`that do not meet criteria for a Manic Episode and periods of depressive symptoms that
`do not meet symptom or duration criteria for a Major Depressive Episode. Bipolar I
`Disorder is distinguished from Cyclothymic Disorder by the presence of one or more
`Manic or Mixed Episodes. If a Manic or Mixed Episode occurs after the first 2 years of
`Cyclothymic Disorder, then Cyclothymic Disorder and Bipolar I Disorder may both be
`diagnosed.
`The differential diagnosis between Psychotic Disorders (e.g., Schizoaffective
`Disorder, Schizophrenia, and Delusional Disorder) and Bipolar I Disorder may be
`difficult (especially in adolescents) because these disorders may share a number of
`presenting symptoms (e.g., grandiose and persecutory delusions, irritability, agitation,
`
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`Bipolar I Disorder
`355
`
`and catatonic symptoms), particularly cross—sectionally and early in their course. In
`contrast to Bipolar I Disorder, Schizophrenia, Schizoaffective Disorder, and Delusional
`Disorder are all characterized by periods of psychotic symptoms that occur in the absence
`of prominent mood symptoms. Other helpful considerations include the accompanying
`symptoms, previous course, and family history. Manic and depressive symptoms may
`be present during Schizophrenia, Delusional Disorder, and Psychotic Disorder Not
`Otherwise Specified, but rarely with sufficient number, duration, and pervasiveness to
`meet criteria for a Manic Episode or a Major Depressive Episode. However, when full
`criteria are met (or the symptoms are of particular clinical significance), a diagnosis of
`Bipolar Disorder Not Otherwise Specified may be made in addition to the diagnosis
`of Schizophrenia, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
`If there is a very rapid alternation (over days) between manic symptoms and
`depressive symptoms (e. g, several days of purely manic symptoms followed by several
`days of purely depressive symptoms) that do not meet minimal duration criteria for a
`Manic Episode or Major Depressive Episode, the diagnosis is Bipolar Disorder Not
`Otherwise Specified.
`
`
`
`I Diagnostic criteria for 296.0x Bipolar I Disorder,
`Single Manic Episode
`
`A. Presence of only one Manic Episode (see p. 352) and no past Major
`Depressive Episodes.
`
`Note: Recurrence is defined as either a change in polarity from depression or
`an interval of at least 2 months without manic symptoms.
`
`. The Manic Episode is not better accounted for by Schizoaffective
`Disorder and is not superimposed on Schizophrenia, Schizophreniform
`Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise
`Specified.
`
`With Postpartum Onset (see p. 386)
`
`Specify if:
`Mixed:
`
`if symptoms meet criteria for a Mixed Episode (see p. 355)
`
`Specify (for current or most recent episode]:
`Severity/Psychotic/Remission Specifiers (see p. 378)
`With Catatonic Features (see p. 582)
`
`
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`356 Mood Disorders
`
`
`
`I Diagnostic criteria for 296.40 Bipolar l Disorder,
`Most Recent Episode Hypomanic
`
`. Currently (or most recently) in a Hypomanic Episode (see p. 338).
`
`. There has previously been at least one Manic Episode (see p. 332) or
`Mixed Episode (see p. 335).
`
`. The mood symptoms cause clinically significant distress or impairment
`in social, occupational, or other important areas of functioning.
`
`. The mood episodes in Criteria A and B are not better accounted for by
`Schizoaffective Disorder and are not superimposed on Schizophrenia,
`Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
`Not Otherwise Specified.
`
`Specify:
`Longitudinal Course Specifiers (With and Without Interepisode
`Recovery) (see p. 387)
`With Seasonal Pattern (applies only to the pattern of Major Depressive
`Episodes) (see p. 389)
`With Rapid Cycling (see p. 390)
`
`
`
`
`
`
`
`I Diagnostic criteria for 296.4x Bipolar l Disorder,
`Most Recent Episode Manic
`
`A. Currently (or most recently) in a Manic Episode (see p. 332).
`
`B. There has previously been at least one Major Depressive Episode (see
`p. 327), Manic Episode (see p. 332), or Mixed Episode (see p. 335).
`
`C. The mood episodes in Criteria A and B are not better accounted for by
`Schizoaffective Disorder and are not superimposed on Schizophrenia,
`Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
`Not Otherwise Specified.
`
`Specify [for current or most recent episode]:
`Severity/Psychotic/Remission Specifiers (see p. 378)
`With Catatonic Features (see p. 582)
`With Postpartum Onset (see p. 386)
`
`Specify:
`Longitudinal Course Specifiers (With and Without Interepisode
`Recovery) (see p. 387)
`With Seasonal Pattern (applies only to the pattern of Major Depressive
`Episodes) (see p. 389)
`With Rapid Cycling (see p. 390)
`
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`Bipolar I Disorder 357
`
`
`
`
`
`I Diagnostic criteria for 296.6x Bipolar l Disorder,
`Most Recent Episode Mixed
`
`A. Currently (or most recently) in a Mixed Episode (see p. 335).
`
`B. There has previously been at least one Major Depressive Episode (see
`p. 327), Manic Episode (see p. 552), or Mixed Episode (see p. 335).
`
`C. The mood episodes in Criteria A and B are not better accounted for by
`Schizoaffective Disorder and are not superimposed on Schizophrenia,
`Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
`Not Otherwise Specified.
`
`Specify (for current or most recent episode):
`Severity/Psychotic/Remission Specifiers (see p. 380)
`With Catatonic Features (see p. 582)
`With Postpartum Onset (see p. 586)
`
`Specify:
`Longitudinal Course Specifiers (With and Without Interepisode
`Recovery) (see p. 387)
`With Seasonal Pattern (applies only to the pattern of Major Depressive
`Episodes) (see p. 389)
`With Rapid Cycling (see p. 390)
`
`
`
`
`
`
`
`I Diagnostic criteria for 296.5x Bipolar I Disorder,
`Most Recent Episode Depressed
`
`. Currently (or most recently) in a Major Depressive Episode (see p. 327).
`
`. There has previously been at least one Manic Episode (see p. 532) or
`Mixed Episode (see p. 535).
`
`. The mood episodes in Criteria A and B are not better accounted for by
`Schizoaffective Disorder and are not superimposed on Schizophrenia,
`Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
`Not Otherwise Specified.
`
`
`
`Specify (for current or most recent episode):
`Severity/Psychotic/Remission Specifiers (see p. 376)
`Chronic (see p. 382)
`With Catatonic Features (see p. 582)
`With Melancholic Features (see p. 385)
`
`(continued)
`
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`358 Mood Disorders
`
`
`
`El Diagnostic criteria for 296.53: Bipolar l Disorder,
`Most Recent Episode Depressed (continued)
`
`With Atypical Features (see p. 384)
`With Postpartum Onset (see p. 586)
`
`Specify:
`Longitudinal Course Specifiers (With and Without Interepisode
`Recovery) (see p. 387)
`With Seasonal Pattern (applies only to the pattern of Major Depressive
`Episodes) (see p. 389)
`With Rapid Cycling (see p. 590)
`
`
`
`
`
`
`
`
`I Diagnostic criteria for 296.7 Bipolar l Disorder,
`Most Recent Episode Unspecified
`
`A. Criteria, except for duration, are currently (or most recently) met for a
`Manic (see p. 352), a Hypomanic (see p. 338), a Mixed (see p. 335), or
`a Major Depressive Episode (see p. 327).
`
`B. There has previously been at least one Manic Episode (see p. 532) or
`Mixed Episode (see p. 535).
`
`C. The mood symptoms cause clinically significant distress or impairment
`in social, occupational, or other important areas of functioning.
`
`D. The mood symptoms in Criteria A and B are not better accounted for
`by Schizoaffective Disorder and are not superimposed on Schizophre-
`nia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Dis—
`order Not Otherwise Specified.
`
`. The mood symptoms in Criteria A and B are not due to the direct
`physiological effects of a substance (e.g., a drug of abuse, a medication,
`or other treatment) or a general medical condition (e.g., hyperthy—
`roidism).
`
`Specify:
`Longitudinal Course Specifiers (With and Without Interepisode
`Recovery) (see p. 587)
`With Seasonal Pattern (applies only to the pattern of Major Depressive
`Episodes) (see p. 389)
`With Rapid Cycling (see p. 590)
`
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