Persistent Depressive Disorder/ Dysthymic Disorder

Dysthymic disorder is common in Western countries, with an estimated lifetime

prevalence of 2.6-6%. Depressive symptoms often start before the age of 21 in more than
half of patients.

Clinical Manifestation

People with persistent depressive disorder chronically feel depressed (See Fig 2). This is
usually seen in people who feel melancholic and sad for a period of at least two years.

The majority of people with dysthymia experience the symptoms for four to five years,
but symptoms can be present for a longer duration of time.

Symptoms may be inconsistent, but they must be present most of the time.

People suffering from dysthymia usually have fewer symptoms than those with major
depressive disorders. However, due to the disease's chronicity, patients also suffer from
adverse effects on lifestyle and functioning.

Diagnosis

According to the DSM-V criteria, patients with the persistent depressive disorder should
have a depressed mood for most of the day, for more days than not, as indicated by either
subjective account or observation by others, for at least 2 years. Patients should also have
at least two other depressive symptoms, which cause impairments in lifestyle and daily
functioning.

During the 2-years of the disturbance, the individual has never been without depression
for more than 2 months at a time. Symptoms of mania should be absent, and symptoms
are not due to other illnesses or substance use.

Depressive symptoms

1. Poor appetite or overeating.

2. Insomnia or hypersomnia.
3. Low energy or fatigue.
 4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.

Bipolar Disorders

Bipolar and related disorders include cyclothymic disorder, Bipolar I Disorder, and
Bipolar II disorder.

These are referred to as "bipolar" because of the presence of two key moods that are seen
in mood disorders.

Since depressive symptoms have already been discussed in the previous section, this
section will give a focused discussion on the clinical features of mania.

Manic Episode

Clinical features

Mania is characterized by an elevated mood, with feelings of elation and euphoria (See
Fig 3).

Patients are unusually energetic, with an inflated sense of confidence. This can be
manifested by unusual productivity and increased mental activity.

Depending on the severity of the symptoms, patients may have racing thoughts or
psychomotor agitation.

Diagnosis

According to DSM-V, patients with manic episodes have a distinct period of abnormally
and persistently elevated, expansive, or irritable mood and abnormally and persistently
increased goal-directed activity or energy, lasting at least 1 week and present most of the
day, nearly every day.
During this period of increased activity, at least three manic symptoms should be present.
If the patient's mood is irritable, the patient should have at least 4 symptoms of mania to
qualify as a manic episode.

These symptoms should be evidently different from previous behavior.

Symptoms should not be secondary to other illnesses of substance use.

The mood disturbance should also be severe to cause impairment lifestyle impairment,
especially in social and occupational functioning.

Manic symptoms

1. Inflated self-esteem or grandiosity.

2. Decreased need for sleep
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Easy distractibility
6. Increase in goal-directed activity or psychomotor agitation
7. Excessive involvement in activities that have a high potential for painful
consequences (e.g., binge drinking, shopping sprees to the point of debt, impulsive
financial investments)

Milder forms of mania are seen in a hypomanic episode. This is characterized by an

elevated mood that is usually observed for at least 4 days.

To classify as a hypomanic episode, patients should have at least three symptoms of

mania, but with less intensity.

Cyclothymic disorder

Some normal people have mood swings and cyclical mood changes. This phenomenon is
referred to as cyclothymic personality or temperament. However, persistent symptoms
may herald a diagnosis of the cyclothymic disorder, which is characterized by cyclic
mood disturbances for at least two years (See Fig 5).

Clinical Manifestation
Cyclothymic disorder is characterized by alternating symptoms of depression and
hypomania.

The depressive phase is characterized by typical symptoms of depression, such as loss of

interest in pleasure in usual activities and unusual sadness.

Typically depressive symptoms are similar to that which is seen in dysthymia because
since they are less severe than symptoms of major depressive disorder.

Opposite symptoms are seen in the hypomanic phase, which is characterized by increased
energy and mental activity. During this time, patients are noted to be highly productive
and creative.

Diagnosis

According to DSM-V, depressive symptoms should be present for at least two years, with
periods wherein hypomanic symptoms are observed. Symptoms should be present in the
majority of the said period without a complete resolution of more than two months.

These symptoms should not meet the criteria for other illnesses or substance use.
Symptoms should also cause significant impairment in the lifestyle and performance of
daily functional activities.

Bipolar I Disorder

Bipolar I disorder was previously known as manic-depressive disorder.

Based on epidemiologic studies, the American population has the highest rates of people
with this disorder, with an incident of 1% of the total population. The age of onset usually
occurs before the age of 25, and this disorder can also be seen in children and
adolescents.

Bipolar I causes severe functional impairment because symptoms of full-blown mania are
disabling. Patients with bipolar disorder are also more prone to committing suicide. One
study documented that one in every four people with Bipolar I disorder had at least one
suicide attempt.
Clinical features and diagnosis

Mixed episodes characterize this wherein features of a manic episode and major
depressive episodes are seen. These symptoms should last for at least one week. The
presence of a full-blown manic episode distinguishes this disorder from other mood
disorders (See Fig 6).

Bipolar II disorder

Similar to Bipolar I disorder, Bipolar II disorders are less common than the major
depressive disorder. Epidemiologic estimates show that Bipolar II disorders have an
incidence of 0.4 to 2% of the American population.

Generally, bipolar II disorders' true incidence is difficult to estimate because diagnosis is

difficult to establish using structured interviews. Patients present before the age of 5 years
later than patients with Bipolar I disorders. Bipolar II disorder is equally seen in both
genders.

Compared to bipolar I, bipolar II patients have slightly less risk of suicidal attempts,
documented at one in every five persons with the disorder.

Clinical features and diagnosis

Patients with Bipolar II disorder have depressive symptoms with periods of hypomania.
Symptoms should be less intense than that of a full-blown manic episode. For diagnosis,
patients should have at least one episode of major depressive disorder and one episode of
hypomania.