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Bipolar Disorders Psychiatry 2

Dr. Besa
First Shifting
24 July 2008

BIPOLAR DISORDER – both manic and depressive • Glutamate & Glycine – neurotoxic effects;
episodes or manic episodes glutamate + hypercortisolemia = depression
alone
HYPOMANIA – manic symptoms that does not Hormones
meet DSM-IV-TR • TSH - depression
CYCLOTHYMIA – less severe form of bipolar
• GH – inh by somatostatin and CRH;
disorder
↓somatostatin in depression, ↑ in mania
DYSTHYMIA – less severe form of major depression
• Prolactin – stim by serotonin, inh by dopamine
History Sleep: depression
• Hippocrates – mania and melancholia
• Jules Falret – folie circulaire: alternating moods ↓lymphocytes: depression
of depression and mania
Brain (in Mania): Increased frequency of abnormal
• Karl Kahlbaum – cyclothymia
hyperintensities in subcortical region
• Emil Kraeplin – bipolar I disorder and
involutional melancholia GENETIC FACTORS
• Family: Depression
Epidemiology • Adoption: 3x increase in bipolar
• Lifetime prevalence: 2.4% • Twins: 50-70%; monozygotic 70-90%, dizygotic
• Bipolar I –equal men & women 16-35%
• Manic episodes • Linkage: chr 18q and 22q; 18 fr mother, 21q in
◦ More common in men schiz & bipolar, 22q (BCR gene) in neuron
◦ Women have higher rate for rapid cyclers growth & axonal guidance
• Age: 5-6 years old, to 50 mean age=30
• Marital status: divorce and single PSYCHOSOCIAL
• Socioeconomic: upper socioeconomic groups
• Life events & envtl stess: depression
• Personality factors: OCD, histrionic &
Comorbidity borderline in depression; dysthymic and
• Substance abuse (self medication with alcohol) cyclothymic d/o in MDD or bipolar I d/o
• Anxiety disorder: worsen prognosis and increase • Psychodynamic Factors
risk of suicide ◦ defense against underlying depression
◦ Abraham: inability to tolerate development
Etiology tragedy; result from tyrannical superego →
intolerable self-critism → euphoric self-
BIOLOGICAL FACTORS satisfaction
- Monoaminergic systems ◦ Lewin: ego overwhelmed by pleasurable
impulses
Biogenic amines
◦ Klein: defensive reaction to depression
• NE & serotonin - depression
• Dopamine - reduced in depression, increased in Diagnosis
mania
- Reduce dopamine: reserpine, BIPOLAR I DISORDER
Parkinson’s dse - Bipolar II: depressive and hypomanic
- Increased dopamine: tyrosine, - Manic ppt by antidepressant tx ≠ bipolar I
amphetamine, buproprion - Criteria for Manic:
(Wellbutrin) • Persistently elevated, expansive and
Other NTs irritable mood, one week
• ACh – agonists produce lethargy, anergia, • 3 or more of the following symptoms:
psychomotor retardation, exacerbate sx of ◦ Grandiosity
depression, reduce sx of mania ◦ Decrease need for sleep
• GABA – reduction in depression ◦ More talkative
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PSYCH2
BIPOLAR DISORDERS

◦ Flight of ideas
◦ Distractibility
◦ Increase in goal = directed activity or
psychomotor agitation
◦ Pleasurable activity with painful
consequences
• Do not meet criteria for mixed episodes
• SEVERE to cause marked impairment or to
necessitate hospitalization
• Not due to substance abuse, general
medical condition (GMC)

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PSYCH2
BIPOLAR DISORDERS

Bipolar I disorder, single manic episode With rapid cycling.


- Manic Episode – 1st manic episode

Table 15.1-14 • Bipolar I disorder, most recent episode


A. Presence of only one manic episode and no past hypomanic (Table 15.1-16)
major depressive episodes. A. Currently (or most recently) in a hypomanic
episode.
Note: Recurrence is defined as either a change in B. There has previously been at least one manic
polarity from depression or an interval of at least 2 episode or mixed episode.
months w/o manic symptoms. C. The mood symptoms cause clinically significant
B. The manic episode is not better accounted for by distress or impairment in social, occupational, or
schizoaffective disorder and is not superimposed other important areas of functioning.
on schizophrenia, schizophreniform disorder, D. The mood episode in criteria A and B are not
delusional disorder, or psychotic disorder not better accounted for by schizoaffective disorder
otherwise specified. and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder, or
Specify if : psychotic disorder not otherwise specified.
Mixed: If symptoms meet criteria for a mixed episode
if the full criteria are currently met for a manic, mixed, Specify if:
or major depressive episode, specify its current clinical Longitudinal course specifies (with and w/o
status and/or features: interepisode recovery)
Mild, moderate, severe w/o psychotic With seasonal pattern (applies only to the
features/severe with psychotic features pattern of major depressive episodes)
With catatonic features, with postpartum onset With rapid cycling.

If the full criteria are not currently met for a manic,


mixed or major depressive episode, specify the • Bipolar I disorder, most recent episode
current clinical status of bipolar I disorder or features
depressed (Table 15.1-17)
of the most recent episode:
A. Currently (or most recently) in a major depressive
In partial remission, in full remission
episode.
With catatonic features
B. There has previously been at least one manic
With postpartum onset
episode or mixed episode.
C. The mood episode in criteria A and B are not
better accounted for by schizoaffective disorder
Bipolar I disorder, recurrent
and are not superimposed on schizophrenia,
- separated by at least 2 months without schizophreniform disorder, delusional disorder, or
significant symptoms of mania or hypomania psychotic disorder not otherwise specified.
If the full criteria are currently met for major
• Bipolar I disorder, most recent episode manic depressive episode, specify its current clinical status
(Table 15.1-15) and /or features:
A. Currently ( or most recently) in manic episode. Mild, moderate, sever w/o psychotic features,
B. There has previously been at least one major sever w/ psychotic features,
depressive episode, manic episode, or mixed Chronic
episode. With catatonic features
C. The mood episode in criteria A and B are not With melancholic features
better accounted for by schizoaffective disorder With atypical features
and are not superimposed on schizophrenia, With postpartum onset
schizophreniform disorder, delusional disorder, or
psychotic disorder not otherwise specified. If the full criteria are not currently met for a major
depressive episode, specify the current clinical status
If the full criteria are currently met for a manic of bipolar I disorder and/or features of the most recent
episode, specify its current clinical status and/or major depressive episode:
features: In partial remission, in full remission
Mild, moderate, severe w/o psychotic Chronic
features/severe with psychotic features With catatonic features
With catatonic features, with postpartum onset With melancholic features
With atypical features
If the full criteria are not currently met for a manic With postpartum onset
episode, specify the current clinical status of bipolar I
disorder and/or features of the most recent manic Specify if:
episode: Longitudinal course specifies (with and w/o
interepisode recovery)
In partial remission, in full remission With seasonal pattern (applies only to the
With catatonic features pattern of major depressive episodes)
With postpartum onset With rapid cycling
Specify if:
Longitudinal course specifies (with and w/o
interepisode recovery) • Bipolar I disorder, most recent episode mixed
With seasonal pattern (applies only to the (Table 15.1-18)
pattern of major depressive episodes)

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PSYCH2
BIPOLAR DISORDERS

A. Currently (or most recently) in a major depressive Mild: Minimum symptom criteria are met for a manic
episode. episode.
B. There has previously been at least one major Moderate: Extreme increase in activity or impairment in
depressive episode, manic episodes or mixed judgment.
episode. Severe without psychotic features: Almost continual
C. The mood episode in criteria A and B are not supervision required to prevent physical harm to self and
better accounted for by schizoaffective disorder other.
and are not superimposed on schizophrenia, Severe with psychotic features: Delusion or
schizophreniform disorder, delusional disorder, or hallucination. If possible, specify whether the psychotic
psychotic disorder not otherwise specified. features are mood- congruent:
Mood- congruent psychotic features: delusion or
If the full criteria are currently met for mixed episode, hallucination whose content is entirely consistent with
specify its current clinical status and /or features: the typical manic themes or inflated worth, power,
Mild, moderate, sever w/o psychotic features, knowledge, identity, or special relationship to deity or
sever w/ psychotic features, famous person.
With catatonic features Mood- incongruent psychotic features: Delusion or
With postpartum onset hallucination whose content does not consistent with
If the full criteria are not currently met for a mixed the typical manic themes or inflated worth, power,
episode, specify the current clinical status of bipolar I knowledge, identity, or special relationship to deity or
disorder and/or features of the most recent mixed famous person. Included are such symptoms as
episode: persecutory delusion (not directly related to grandiose
In partial remission, in full remission ideas or themes), thought insertion, and delusions of
With catatonic features being controlled.
With postpartum onset In partial remission: Symptoms of manic episode are
present but full are not met, or there is a period w/o any
Specify if: significant symptoms of manic episode lasting 2 months
Longitudinal course specifies (with and w/o following the end of manic episode.
interepisode recovery) In full remission: During the past 2 months no significant
With seasonal pattern (applies only to the signs or symptoms of disturbance were present.
pattern of major depressive episodes)
With rapid cycling.
Hypomanic
- Persistently elevated, expansive and irritable
• Bipolar I disorder, most recent episode mood, lasting at least 4 days
unspecified (Table 15.1-19) - 3 or more of same symptoms
A. Criteria, except for duration, are currently ( or
most recently) met for a manic, a hypomanic, a - Uncharacteristic of the person
mixed, or major depressive episode. - Change in functioning observable by others
B. There has previously been at least one manic - NOT SEVERE to cause marked impairment or
episode or mixed episode. to necessitate hospitalization
C. The mood symptoms cause clinically significant - Not due to substance abuse, GMC
distress or impairment in social, occupational, or
other important areas of functioning.
D. The mood symptoms in criteria A and B are not Mixed Episode
better accounted for by schizoaffective disorder - Met for both manic and depress episodes
and are not superimposed on schizophrenia, everyday for 1 week
schizophreniform disorder, delusional disorder, or - Severe to cause impairment
psychotic disorder not otherwise specified.
E. The mood symptoms in criteria A and B are not
- Not due to substance, GMC
due to the direct physiological effects of a
substance( e.g. a drug of abuse, medication, or Criteria for Severity/Psychotic/Remission
other treatment) or general medical condition( Specifiers for Current (or Most Recent MIXED
e.g. hyperthyroidism). episode Table 15.1-11
Specify if: Note: Code in fifth digit. Mild, moderate, severe w/o
Longitudinal course specifies (with and w/o psychotic features, severe w/psychotic features can be
interepisode recovery) applied only if the criteria are currently met for mixed
With seasonal pattern (applies only to the episode. In partial remission and in full remission can be
pattern of major depressive episodes) applied to a mixed episode in bipolar I disorder only if it is
With rapid cycling. the most recent type of mood episode.
Mild: No more than minimum symptom criteria are met
for a manic episode and major depressive episode.
Moderate: Symptoms or functional impairment between
Criteria for Severity/Psychotic/Remission
mild and severe.
Specifiers for Current (or Most Recent MANIC Severe without psychotic features: Almost continual
episode (Table 15.1-10) supervision required to prevent physical harm to self and
Note: Code in fifth digit. Mild, moderate, severe w/o other.
psychotic features, severe w/psychotic features can be Severe with psychotic features: Delusion or
applied only if the criteria are currently met for manic hallucination. If possible, specify whether the psychotic
episode. In partial remission and in full remission can be features are mood- congruent or mood- incongruent:
applied to a manic episode in bipolar I disorder only if it is
the most recent type of mood episode.

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PSYCH2
BIPOLAR DISORDERS

Mood- congruent psychotic features: delusion or Longitudinal course specifies (with and w/o
hallucination whose content is entirely consistent with interepisode recovery)
the typical manic themes or depressive themes. With seasonal pattern (applies only to the pattern
Mood- incongruent psychotic features: Delusion or of major depressive episodes)
hallucination whose content does not involved with With rapid cycling.
the typical manic theme or depressive theme.
Included are such symptoms as persecutory delusion
(not directly related to grandiose ideas or themes), Recurrent Course:
thought insertion, and delusions of being controlled. • With rapid cycling: BID, BIID
In partial remission: Symptoms of mixed episode are • With seasonal pattern: BID, BIID, MDD
present but full are not met, or there is a period w/o any
significant symptoms of mixed episode lasting 2 months
• With or without full interepisode recovery: BID,
following the end of mixed episode. BIID, MDD
In full remission: During the past 2 months no significant • With postpartum onset: BID, BIID, MDD, BPD
signs or symptoms of disturbance were present. (brief psychotic disorder)
• Rapid cycling: BID, BIID
◦ Female with depressive and hypomanic
BIPOLAR II DISORDER episodes
- One or more depressive episode ◦ Stress or drug treatment
- At least one hypomanic episode
- Never had manic or mixed episode
◦ 4 episodes in 1 year
- Not due to schizophrenia
- Significant impairment SPECIFIERS (MOST RECENT EPISODE )

A. Presence (or history) of one or more major depressive With Psychotic Features
episode. - Poor prognostic indicator
B. Presence (or history) of the least one hypomanic - Bipolar I: families of probands with psychotic
episode. depression
C. There has been a manic episode or mixed episode. - Mood congruent: “I deserve to be punished
D. The mood symptoms in criteria A and B are not better
accounted for by schizoaffective disorder and are not bec I am so bad”
superimposed on schizophrenia, schizophreniform - Mood incongruent: may have schizoaffective
disorder, delusional disorder, or psychotic disorder not disorder or schizophrenia
otherwise specified. - Poor prognosis: long duration of episodes,
E. The symptoms cause clinically significant distress or temporal dissociation, poor premorbid history
impairment in social, occupational, or other important - Tx: antipsychotic drugs + antidepressants or
areas of functioning. mood stabilizers
Specify current or most recent episode:
Hypomanic: if currently ( or most recently ) in a With Melancholic Features
hypomanic episode.
Depressed: if currently ( or most recently ) in a major
- Severe anhedonia, early morning awakening,
depressive episode. weight loss, and profound feelings of guilt
If the full criteria are currently met for major depressive - Assoc with changes in ANS and endocrine fcns
episode, specify its current clinical status or features: - “endogenous depression”: depression in the
Mild, moderate, severe w/o psychotic features absence of external life stressors
severe w/psychotic features. Note: Fifth-digit codes
cannot be used here because the code for bipolar II
disorder already uses the fifth digit. Specify if:
Chronic With melancholic features: (can be applied to the
With catatonics features current or most recent major depressive episode in
With melancholic features major depressive disorder and to a major depressive
With atypical features episode in bipolar I or bipolar II disorder only if it is the
With postpartum onset most recent type of mood episode).
A. Either of the following, occurring during the most
If the full criteria are not currently met for a hypomanic or severe period of the current episode:
major depressive episode, specify its current clinical status (1) Loss of pleasure in all, or almost all, activities.
or features of the bipolar II disorder and/or features of the (2) Lack of reactivity to usually pleasurable stimuli
most recent major depressive episode ( only if it is the (does not feel much better, even temporarily,
most recent type of mood episode): when something good happens).
In partial remission, In full remission: Note : Fifth- B. Three (or more) of the following:
digit codes cannot be used here because the code for (1) Distinct quality of depressed mood (i.e., the
bipolar II disorder already uses the fifth digit. depressed mood is experienced after the death
Chronic of loved one)
With catatonics features (2) Depression regularly worse in the morning
With melancholic features (3) Early morning awakening (at least 2 hours before
With atypical features usual time of awakening)
With postpartum onset (4) Marked psychomotor retardation or agitation
Specify if: (5) Significant anorexia or weight loss
(6) Excessive or inappropriate guilt

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PSYCH2
BIPOLAR DISORDERS

Postpartum Onset
Specify if:
Postpartum Onset (can be applied to the current or
With Atypical Features most recent major depressive, manic, or mixed episode
in major depressive disorder, bipolar I disorder, bipolar II
- Reversed vegetative symptoms; sx pattern: disorder; or to brief psychotic disorder)
hysteroid dysphoria Onset of episode within 4 weeks postpartum.
- Younger onset of age
- More severe psychomotor slowing
- More frequent coexisting diagnoses of panic Chronic
disorder, substance abuse or dependence, and Specify if:
somatisation disorder Chronic (can be applied to the current or most recent
major depressive episode in major depressive disorder
- Long term cause and to a major depressive episode in bipolar I or II
disorder only if it is the most recent type of mood
Specify if: episode)
With Atypical Features (can be applied when these Full criteria for major depressive episode have been
features predominate during the most recent 2 weeks of met continuously for at least the past 2 years.
a current major depressive episode in major depressive
disorder or in bipolar I or bipolar II disorder when a
current major depressive episode is the most recent
type of mood episode,or when these features
predominated during the most recent 2 years of
DESCRIBING COURSE FOR RECURRENT EPISODES
dysthymic disorder: if the major depressive episode is
not current, it applies if the features predominates Rapid Cycling
during 2 weeks period) - Female
A. Mood activity ( i.e., mood brightens in response to - Depresseive and hypomanic episodes
actual or potential positive events) - Pathogenesis: stress or drug treatment
B. Two (or more) of the following features:
(1) Significant weight gain or increase in appetite - At least 4 episodes within 12 month period
(2) Hypersomnia
(3) Leaden paralysis ( i.e., heavy, leaden, feelings Specify if:
arms or legs ) Rapid Cycling (can be applied to bipolar I disorder or
(4) Long- standing pattern of interpersonal rejection bipolar II disorder)
sensitivity ( not limited to episodes mood At least four episode of a mood disturbance in the previous
disturbance) that results in significant social or 12 months that meet the criteria for major depressive,
occupational impairment. manic, mixed, or hypomanic episode.
C. Criteria are not met for with melancholic features or Note: Episode are demarcated either by partial or full
with catatonic features during the same episode. remission for at least 2 months or switch to an episode of
opposite polarity (e.g., major depressive episode to manic
episode).
With Catatonic Features
- Most commonly schizophrenia and mood
disorder Seasonal Pattern
- Prognostic and tx significance - Most commonly winter
- Seasonal affective disorder
Specify if: - 2 evidence
With Catatonic Features (can be applied to the 1. Likely to respond to light therapy
current or most recent major depressive episode, manic 2. Decreased metabolic activity in the orbital
episode, or mixed episode in major depressive disorder, frontal cortex and left inferior parietal lobe
bipolar I or bipolar II disorder).
The clinical picture is dominated by at least 2 of the
Specify if:
following:
Seasonal Pattern (can be applied to the pattern of major
(1) Motoric immobility as evidence by catalepsy
depressive episode in bipolar I disorder, bipolar II disorder,
(including waxy flexibility) or stupor.
or major depressive disorder, recurrent).
(2) Excessive motor activity (that is apparently
purposeless and not influenced by external stimuli) A. There has been a regular temporal relationship
(3) Extreme negativism (an apparently motiveless between the onset of major depressive episode in
resistance to all instruction or maintenance of a bipolar I or II disorder or major depressive disorder,
rigid posture against attempts to be moved) or recurrent and a particular time of the year (e.g.,
mutism regular appearance of the major episode in the fall or
(4) Peculiarities of voluntary movement as evidenced winter).
by posturing (voluntary assumption of NOTE: do not include cases in which there is an
inappropriate or bizarre posture), stereotyped obvious effect of seasonal-related psychosocial
movements, prominent mannerism, or prominent stressor (e.g, regularly being unemployed every
primacing winter).
(5) Echolalia or echopraxia B. Full remission (or a change from depression to mania
or hypomania) also occur at a characteristic time of
the year (e.g., depression disappears in the spring).

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PSYCH2
BIPOLAR DISORDERS

C. In the last 2 years, two major depressive episode • Other Substance-Related Disorders: ppt an
have occurred that demonstrate the temporal episode of illness or patient’s attempt to treat
seasonal relationship defined in criteria A and B, and
no non seasonal major depressive episode have
their own illnesses; cocaine & amphetamine
occurred during the same period • Medical Conditions: older persons; medical
D. Seasonal major depressive major depressive episodes condition/drugs taking = depression; cancer
(as describe above) substantially outnumber the non-
seasonal major depressive episodes that may have
occurred over individual’s lifetime.
MSE
Gen description: Euphoric, very loud voice
Longitudinal Course Specifiers Mood, affect,
Specify if (can be applied to recurrent major depressive feeling: Elevated mood
disorder or bipolar I or II disorder): Loud voice, flight of ideas, Not
With full interepisode recovery: in full remission is Speech:
connected with each other
attained between two most recent mood episodes Perceptual
Without full interepisode recovery: if full remission is disturbance: Hallucination, delusion, grandiose
not attained between the two most recent mood episode. Preoccupied with sexual,
Thought:
political,religious, persecutory ideas
NON-DSM-IV-TR TYPES Sensorium and Intact memory, oriented to time,
• Endogenous-reactive continuum
memory: place and person
- Endogenous depressions are biological;
Impulse control: Poor
Reactive depressions are psychological Judgement and Very poor, no insight about their
- Endogenous depression: similar to MDD w/
insight: illness
psychotic features or melancholic features
Reliability: Notoriously unreliable
- Reactive depression: initial insomnia,
anxiety, emotional lability, multiple somatic Course and Prognosis
complaints
BID
• Primary Depression: Mood disorders caused by • Graphing the course patient’s disorder
GMC • Starts with depression (usually)
• Secondary Depression: substance-induced mood • Recurring disorder
disorder • Manic episodes have rapid onset, untreated
• Double Depression: MDD superimposed on episodes lasts 3 months
dysthymic d/o • Time between episodes decreases
• Depressive equivalent: forme fruste of • 4 or more episodes a year  rapid cycler
depressive episode • Poor prognosis: poor occupational status,
alcohol dependence, psychotic features, male
Clinical Features gender
MANIC EPISODES
BIID
• Hallmark: Elevated/euphoric, expansive,
• Diagnosis is stable
irritable mood
• Chronic disease that needs loner term
• Excessive alcohol intake to self-medicate
treatment strategies
• Disinhibited nature
• Act impulsively with sense of conviction and
purpose Treatment
• Preoccupied with religious, political, financial, ACUTE MANIC
sexual, persecutory ideas • Mood stabilizers:
• In adolescents: often misdiagnosed as antisocial
◦ Lithium = best; 900-1800 mg/day
personality disorder or schizophrenia
◦ Valproate = 750-2000 mg/day
◦ Carbamazepine = 800-1800 mg/day
BIPOLAR II DISORDER ◦ Clonazepam
• MDD + hypomanic • Atypical and typical antipsychotic (alone)
• More marital disruption ◦ Risperdal
• Onset at an earlier age ◦ Abilify

C OEXISTING DISORDERS ACUTE BIPOLAR DEPRESSION


• Anxiety: mixed anxiety-depressive disorder • Anti depressants induce cycling, mania,
• Alcohol Dependence: women hypomania
• Antidepressants + mood stabilizer
• Lamotrigine
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PSYCH2
BIPOLAR DISORDERS

• Symptomatically a form of BIID


Maintainance: Lithium, valproate = get • Chronic, fluctuating disturbances with many
therapeutic level periods of hypomania and depression
• Positive history for BID

OTHER MOOD DISTURBANCES


DYSTHYMIA DEPRESSIVE DISORDER NOS
• Minor Depressive Disorder
• Less severe depression ◦ at least 2 but less than 5 symptoms
• Patient complains that they are always • Recurrent Brief Depressive Disorder
depressed ◦ less than 2 weeks
• Usually early onset ◦ at least once a month for 12 months
• 5-6% of general population ◦ not associated with menstrual cycle
• No gender difference • Premenstrual Dysphoric Disorder
• Coexists with anxiety disorder, substance ◦ late luteal phase dysphoric disorder
abuse, borderline psychotic disorder ◦ mood / behavior / physical symptoms
• Psychosocial Factors: results from personality ◦ occurs at specific time in menstrual cycle
and ego development and culminates in and resolves between menstrual cycle
difficulty adapting to adolescence and early • Post Psychotic Depressive Disorder
adulthood ◦ Major Depressive Disorder during residual
phase
C RITERIA ◦ vulnerability to mental illness which lowers
• Depressed for most of the day for at least 2 self-esteem
years • Bipolar Disorder NOS
• 2 or more of the following: ◦ Mixed Anxiety Depressive Disorder
◦ Poor appetite/overeating ◦ Atypical Depression
◦ Insomnia/hyperinsomnia
◦ Low energy/fatigue SECONDARY MOOD DISORDER
◦ Low self-esteem • Mood disorder due to GMC
◦ Poor concentration/difficulty making • Substance induced mood disorder
decisions
◦ Feelings of hopelessness
• Has never been without the symptoms for > 2
Classmates.. ung treatment, dysthymia & cyclothymia at others, paread nlng sa book..
months
senxa na kng dq na nalagay ung tx ung krugtong ng limpak2 na tables (sna salapi
• No major depression/mania/hypomania/mixed nlng!).. ndi na kc un diniscuss, e parang mas impt ung mga gamot, kc un din nmn ang
episodes tnatanong sa exam.. ska ung iba, sa MDD rin... (lulusot pa o!).. tnx2.. God bless! –malta
• Not due to psychotic disorder
• Not due to substance abuse or GMC Tnong: paano kbisaduhin ang buong MIMS o PPDr? Sadya bang lakas chamba lng ang
medthera? Kung may swerte man, possible ba na kng lhat ay naitama ay considered na
C LINICAL FEATURES : “batugan” “luck”? hehehe..  bangag!
• Habitual gloom, brooding, lack of joy in life,
preoccupation with inadequacy Lunes na nmn po.. ansaya! surg path → medthera → pedia (w/dr.dr!).. life!
• Long-standing, fluctuating, low-grade
depression experienced as part of habitual self

TREATMENT
• Pharmacotherapy
• Psychotherapy
◦ New ways of thinking and behaving to
replace negative attitude
◦ Allowing personal behavior goals to
increase activity, provide pleasant
experiences, ways to relax
◦ Ways of coping with stress

CYCLOTHYMIA
• Lesser BIID

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