MOOD DISORDERS (CHAPTER 8 KAPLAN)

Dr. Agnes Padilla

MAJOR DEPRESSIVE DISORDER ETIOLOGY AND PATHOPHYSIOLOGY

- Mood: a pervasive and sustained emotion or feeling 1. Biological factors
tone that influence a person’s behavior and colors his - Norepinephrine: downregulation or decreased
or her perception of being in the world sensitivity of β adrenergic receptors
- Occurs without a history of a manic, mixed, or - Serotonin: depletion à precipitated depression
hypomanic episode. 2. Genetic factors – Hereditary
- Must last at least 2 weeks, and experiences at least - Parent affected with a mood disorder à offspring
4 symptoms from a list that includes: will have risk for development
o Changes in Appetite and Weight - Both parents are affected, 2x risk
o Changes in Sleep and Activity 3. Psychosocial factors - Life Events and Environmental
o Lack of Energy Stressors
o Feelings of Guilt - Recent stressful events are the most powerful
o Problems Thinking and Making Decisions predictors of the onset of depressive episodes
o Recurring Thoughts of Death or Suicide
DIAGNOSIS
EPIDEMIOLOGY AND PREVALENCE Five (or more) of the following symptoms have been
- Highest prevalence in a person’s lifetime (Rate : 5 - presented during the same 2-week period and
17%) represent a change from previous functioning: at least
- 2-fold greater prevalence in women than men one of the symptoms is either (1) depressed mood or
o Difference psychosocial stressors for each (2) loss of interest or pleasure.
gender (e.g. effects of childbirth, hormonal 1. Depressed mood
differences) 2. Loss of interest or pleasure
- Increased risk for comorbid conditions 3. Weight loss or gain
- Mean age of onset: 40 years old 4. Insomnia or hypersomnia
- 50% onset at 40-50 y.o.; Childhood or Old age 5. Psychomotor agitation or retardation
- No close relationships 6. Fatigue
- Divorced 7. Feeling worthless/inappropriate guilt
- No predilection in Socioeconomic status or Race 8. Decreased concentration
9. Thoughts of death/suicide
COMORBIDITY
Usually accompanied with a strong inner connection by Specifiers (Symptom Features)
other mental disorders - With anxious distress
- Panic Disorder - With mixed features
- Alcohol abuse or Dependence - With melancholic features
- Social Anxiety Disorder - With atypical features
- Obsessive-Compulsive Disorder - With mood-congruent psychotic features
- Bulimia Nervosa - With mood-incongruent psychotic features
- Borderline Personality Disorder - With catatonia
- With peripartum onset
- With seasonal pattern

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 DIFFERENTIAL DIAGNOSIS - Vegetative Symptoms: abnormal menses and
decreased interest and performance in sexual
DDx Rule in Rule out
activities
(+) female prevalence (-) mania episode
Bipolar I
(+) major depressive
Disorder In Children and Adolescents
episode
- School Phobia
Bipolar II (+) major depressive (-) hypomania
- Excessive clinging to parents
Disorder episode episode
(+) depressive episode (-) subaffective or
In Older Peoples
including loss of subclinical
- More common compared to the general population
interest, feelings of disorder
Dysthymia - Correlated with low socioeconomic status, the loss of
inadequacy and guilt, particularly low-
(Persistent a spouse, a concurrent physical illness, and social
poor appetite, grade symptoms
Depressive isolation
insomnia, low energy, and depressed
Disorder) - Underrecognition because the disorder appears more
poor concentration; mood for at least
often with sematic complaints in this age group
No manic episode or 2 years
hypomanic episode
MENTAL STATUS EXAMINATION
(+) female prevalence (-) sustained and
(+) restlessness and excessive anxiety - Stooped posture
Generalized
easily fatigued, (+) and worry, (-) GENERAL - No spontaneous movements
Anxiety
difficulty muscle tension APPEARANCE - Not maintaining eye contact,
Disorder
concentrating, (+) usually downcast averted gaze
sleep disturbance Generalized psychomotor retardation
BEHAVIOR
or agitation
CLINICAL FEATURES - Depressed, sad, hopeless or irritable
MOOD AND
Depressive Episodes (children and adolescents)
AFFECT
- Key symptoms: a depressed mood and a loss of - Congruent affects
interest/pleasure SPEECH Decreased rate and volume
o Feel blue - Nondelusional preoccupations about
o Hopeless THOUGHT loss, guilt, suicide and death
o In the dumps CONTENT - Suicidal ideation and attempt with
o Worthless or without plan
- 2/3 contemplate suicide THOUGHT - Poverty of content of speech
- 10-15% commit suicide PROCESS - Thought Blocking
- 97% complain about reduced energy - Mood congruent delusion
PERCEPTION
o Difficulty finishing tasks - Psychotic depression
o Impaired at school or work ORIENTATION Oriented to person, place and time
o Lacks motivation to take new projects MEMORY Depressive Pseudodementia
- 80% complain of trouble sleeping CONCENTRATION Impaired
o Morning wakening JUDGEMENT Exaggerated symptoms, disorder and
o Multiple wakenings at night AND INSIGHT life problems
- Anxiety affects as many as 90% of all depressed
patients

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 COURSE GOOD INDICATORS POOR INDICATORS
Premorbid - Mild episodes - Coexisting dysthymic
- Usually no premorbid personality disorder - Absence of psychotic disorder
- Majority of patients exhibited significant depressive symptoms - Alcohol and other
symptoms prior to first identified episode. - Short hospital stay substance abuse
- History of solid - Anxiety disorder
Onset friendship, stable symptoms
- 50% 1st episode occurs before age 40 years family, sound - More than one
- Later onset with absence of family history of mood functioning 5 yrs prior depressive episodes
disorders, antisocial PD, and alcohol abuse to illness - Men are more likely to
- Absence of comorbid have chronically
Duration psychiatric disorder impaired course
- Untreated lasts 6-13 mos vs treated lasts 3 mos - No more than 1
- Withdrawal of antidepressants before 3 mos hospitalization
results in return of symptoms - Advanced age of onset
- Mean episode is 5 to 6 (over 20-years)
TREATMENT AND MANAGEMENT
Development of Manic Episodes Hospitalization

- 5-10% have manic episodes 6-10 years after first - Risk of suicide or homicide
depressive episode - A gross inability to get food/shelter
- Mean age of switch is 32 yrs - A rapid progression of signs and symptoms
- Often occurs after 2-4 depressive episodes - Rupture of social support
- In need of a diagnostic procedure
PROGNOSIS - Outpatient: absence of suicidal ideations and
- Not a Benign disorder: Tends to be chronic, patients outpatient management is acceptable
tend to relapse
- Hospitalization: Psychosocial Therapy
o Hospitalized patients on 1st episode have 50% - Most studies found that cognitive therapy is equal in
recovery efficacy to pharmacotherapy and HAS fewer adverse
o Recoveries after repeated hospitalization effects and better followup
decreases over time - Though many clinicians use the
- Unrecovered Patients remain affected with PSYCHOANALYTICALLY ORIENTED as their primary
dysthymic disorder method
- Recurrence: - Alleviates depressive episodes
o 25% first 6 mos after hospital discharge - Prevents recurrence by helping
o 30-50% after 2 yrs patients identify and test negative
o 50-75% in 5 yrs COGNITIVE cognitions; develops alternative,
- Generally, as patient experiences more and more flexible, and positive ways of
depressive episodes, time between episodes shortens, thinking and rehearse new
and severity of increases cognitive and behavioral responses
- Most effective method for severe
INTERPERSONAL MDD when the treatment of
choice is psychotherapy alone

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 - Focuses on one or two of a - Preliminary studies have shown
patient’s current interpersonal recurrent MDD went into
problems remission when treated with VNS
- Usually consists of 12 to 16 weekly - Mechanism of action of is
sessions unknown
- Characterized by an active - Use of very short pulses of
therapeutic approach magnetic energy to stimulate
Based on the hypothesis that nerve cells in the brain
maladaptive behavioral patterns - Produces focal secondary electrical
BEHAVIOR result in a person’s receiving little TRANSCRANIAL stimulation of targeted cortical
feedback and perhaps outright MAGNETIC regions
rejection from society STIMULATION - Nonconvulsive, requires no
- Based on psychoanalytic theories anesthesia, has a safe side effect
about depression and mania profile, and is not associated with
- Goal is to effect a change in a cognitive side effectstherapeutic
patient's personality structure or approach
character (e.g. capacity to grieve , - Exhibits significant transient
for intimacy, interpersonal trust), SLEEP benefits
PSYCHOANALYTICALLY
not simply to alleviate symptoms DEPRIVATION - Positive results are typically
ORIENTED
- Treatment often requires the reversed by the next night
patient to experience periods of - Was introduced in 1984 as a
heightened anxiety and distress treatment for SAD (mood
during the course of therapy, disorder with a seasonal pattern)
which may continue for several - Involves exposing the affected
years patient to bright light in the range
PHOTOTHERAPY of 1,500 to 10,000 lux or more,
Pharmacotherapy - Antidepressants typically with a light box that sits
- TRICYCLIC DRUGS (TCA) - IMIPRAMINE, on a table or desk
CLOMIPRAMINE - Patients sit in front of the box for
- SERUM SEROTONIN REUPTAKE INHIBITORS (SSRI) - approximately 1 to 2 hours before
FLUOXETINE, CITALOPRAM dawn each day
- SERUM NOREPINEPHRINE REUPTAKE INHIBITORS - Involves the induction of
(SNRI) - DULOXETINE generalized seizures
- MONOAMINE OXIDASE INHIBITORS (MAOI) - - Seizures should last at least 25
TRANYLCYPROMINE, PHENELZINE sec
ELECTROCONVULSIVE
- ATYPICAL ANTIDEPRESSANTS - MIRTAZAPINE - Procedure is repeated 2 to 3 times
THERAPY
- SEROTONIN MODULATORS – TRAZODONE a week (total of 6-12 treatments)
- Most common side effects:
Other Interventions anterograde and retrograde
memory loss
- Designed for the treatment of
VAGAL NERVE
epilepsy found that patients
STIMULATION
showed improved mood

E. YV. 4
 CASE o More common in those who did not graduate
A 79-year-old man is brought in by his family after from college
refusing to drink fluids for 24 hours. For the past 3
weeks, the patient has shown worsening signs and DSM-V CRITERIA
symptoms of major depression (decreased energy,
crying spells, suicidal ideation, anorexia
with weight loss, and guilt), culminating in a refusal to
eat or drink. He continues to refuse to eat or drink, is
suicidal, and is probably experiencing auditory
hallucinations. He has had episodes similar to this one
in the past, although no episodes of mania have been
described.

Diagnosis: Major Depressive Disorder, Recurrent; with

psychotic features

Action Plan
- Close observation in the hospital
- Intravenous hydration
- Electroconvulsive therapy (ECT)

BIPOLAR I DISORDER
- Distinct period of abnormal mood lasting at least 1
week of alternating periods of elation and
depression
o At least one manic episode, with or without
depressive episodes
- Syndrome of a complete set of manic episode
accompanying the depressive symptoms
o Periods of Depression - fulfills criteria for major
depressive disorder
o High Risk for Suicide
§ 6% onset of >20 years old
§ 30-40% Self harm
- Lifetime Prevalence of 0 to 2.4%
- Equal prevalence between males and females
o Manic episodes are more common in men
o Depressive episodes are more common in
women
o Manic episodes occur in women à present a
mixed type
- Onset ranges from childhood (5 or 6 years old) to 50
years old (even older in rare cases); mean age of 30
years
- Upper Socioeconomic groups

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 MENTAL STATUS EXAMINATION

COMPONENT MANIC DEPRESSION

Flamboyant; Generalized
psychomotor
SUBTYPES sexually
retardation; Stooped
GENERAL provocative
Based on the symptoms of the most recent episode posture, no
APPEARANCE dressing and spontaneous
SINGLE MANIC EPISODE RECURRENT
- Patient must have at Manic episodes are makeup movements; downward,
averted gaze
least one manic considered distinct when
Hyperactive Hand wringing and hair
episode they are separated by at BEHAVIOR pulling may be
- Patients who are least 2 months without observed. Hypoactive.

having their first significant symptoms of - Great or happy, Social withdrawal;

usually elevated,
episode of bipolar I mania or hypomania generalized
MOOD AND expansile or euphoric
disorder depression decreased activity
AFFECT - Mood is not usually
cannot be appropriate to the
situation.
distinguished from
Speech is Decreased rate and
patients with major volume of speech;
pressured and
depressive disorder respond to questions
SPEECH with an increased with single words and
rate, often loud. exhibit delayed
CLINICAL FEATURES
responses to questions
Extreme moods of feeling really high, very active and
THOUGHT Grandiose Nondelusional
euphoric (‘manic’); or feeling really low (‘depression’) ruminations about loss,
CONTENT Delusions
guilt, suicide, and death
Disorganized and sped Customarily have
THOUGHT up, as reflected by negative views of the
PROCESS rapid speech with a world and of
“flight of ideas” themselves

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 Hallucinations may Delusions and/or TREATMENT
PERCEPTION be present
hallucinations may be
- Patient’s safety must be guaranteed.
present
- A complete diagnostic evaluation of the patient is
Most patients are Most depressed
patients are oriented to necessary
oriented to person,
person, place, and time, - A treatment plan that addresses not only the
place, and time. although some may
ORIENTATION/ immediate symptoms but also the patient’s
not have sufficient
SENSORIUM energy or interest to
prospective as well being should initiated
answer questions.
Depressive Hospitalization
pseudodementia
- First and most critical decision: hospitalize a patient
Poor insight Depressed patients'
descriptions of their or attempt outpatient treatment
disorder are often - Clear indications for hospitalization are the ff:
INSIGHT
hyperbolic; they o The risk of suicide or homicide
overemphasize their
o Grossly reduced ability to get food and shelter
symptoms, their
disorder, and their life o Need for diagnostic procedures
problems.
Poor/impaired Patients may or may Psychosocial Therapy
JUDGEMENT judgment
not have impaired
- Either pharmacotherapy or psychotherapy alone is
judgment.
effective, at least in patients with mild major
depressive episodes, and the regular use of combined
DIFFERENTIAL DIAGNOSIS
therapy adds to the cost of treatment and exposes
- Confused with personality, substance use,
patients to unnecessary adverse effects
schizophrenic, depressive and axiety disorders
o Cognitive therapy
- Certain features, especially in combination, are
o Interpersonal therapy
predictive e.g. Early age of onset + Family History
o Behavior therapy
- Depend on which episode the patient is currently in
DEPRESSIVE MANIC
Vagal Nerve Stimulation
Major Depressive - Bipolar I Disorder
Experimental stimulation of the vagus nerve in several
Disorder - Bipolar II Disorder
- Cyclothymic Disorder studies designed for the treatment of epilepsy found
that patients showed improved mood
- Mood Disorder caused by a
general medical condition
Transcranial Magnetic Stimulation
- Substance-induced mood
disorder It involves the use of very short pulses of magnetic
energy for the treatment of depression in adult
For manic symptoms, the patients who have failed to achieve satisfactory
following personality disorders improvement from one prior antidepressant
need special consideration: medication at or above the minimal effective dose and
- Borderline duration in the current episode
- Narcissistic
- Histrionic Sleep Deprivation
- Antisocial May precipitate mania in patients with bipolar
disorder and temporarily relieve depression in those
who have unipolar depression

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Phototherapy - Risperidone
Exposing the affected patient to bright light in the - Quetiapine
range of 1.500 to 10,000 lux or more, typically with a - Ziprasidone
light box that sits on a table or desk. Patients sit in - Aripriprazole
front of the box for approximately 1-2 hours before
dawn each day, although some patients may also COURSE
benefit from exposure after dusk. - Bipolar I disorder most often starts with depression;
it is a recurring disorder
Pharmacotherapy o 75% in women
o 67% in men
- Most patients experience both depressive and manic
episodes
o 10-20% experience only manic episodes
§ Rapid onset (hours or days) but may evolve
about 3 months
- As the disorder progresses, the time between
episodes often decreases

PROGNOSIS
- Patients with bipolar I disorder have poorer
prognosis than do patients with major depressive
disorder
- One third of all patients with bipolar disorder have
chronic symptoms and evidence of significant social
decline
GOOD INDICATORS POOR INDICATORS
- Short duration of - Premorbid occupational
manic episodes status
- Advanced age of onset - Alcohol Dependence
- Few suicidal thoughts - Psychotic Features
- Few coexisting - Depressive Features
psychiatric or medical - Interepisode depressive
problems features
- Male gender

CASE
Ms. G, a 42 year-old housewife and a mother of
ACUTE MANIA ACUTE BIPOLAR DEPRESSION
a 4-year old boy developed symptoms of hypomania and
- Lithium Carbonate - Lithium
later frank mania without psychosis, when her only son
- Valproate - Carbamazepine
was diagnosed with acute lymphocytic leukemia.
- Carbamazepine and - Lamotrigine
When her son was diagnosed and subsequently
Oxcarbazepine
hospitalized, he required painful medical tests and
- Clonazepam and
emergency chemotherapy, which made him very ill. The
Lorazepam
doctors regularly barraged Ms.G with bad news about
- Olanzapine
his prognosis during the first few weeks of his illness.

E. YV. 8
 Ms.G was ever present with her son at the COMORBIDITY
hospital, never sleeping, always caring for him, yet the - Alcohol abuse or dependence
pediatricians noted that as the child become more - Panic disorder
debilitated and the prognosis more grim, she seemed to - Obsessive-compulsive disorder
bubble over with renewed cheerfulness, good humor, and - Social Anxiety
high spirits. She could not seem to stop herself from
cracking jokes to the hospital staff during her son’s ETIOLOGY
painful procedures, and as the jokes became louder and - Idiopathic condition; heredity plays a significant role
more inappropriate, the staff grew more concerned. - Family history
During her subsequent psychiatric consultation, Ms. G o Conveys greater risk for mood disorders in
reported that her current “happiness and optimism” general
were justified by her sense of “oneness” with Mary, the o Much greater risk for bipolar disorder
mother of God. o Unipolar disorder - most common form of mood
“We are together now, she and I, and she has disorder in families of bipolar probands
become a part of me. We have a special relationship,” - Twin studies: Monozygotic twins of 70 to 90%
she winked. Despite these statements, Ms. G was not compared with same-sex dizygotic twins of 16 to
psychotic and said that she was “speaking 35%
metaphorically, of course, only as a good Catholic - Linkage studies
would.” Her mania resolved when her son achieved o Chromosome 21q - linkage or association to both
remission and was discharged from the hospital. schizophrenia and bipolar disorder
(Courtesy of JC Markowitz, M.D., and BL Milrod, M.D.) o Chromosome 18q and 22q are the 2 regions with
strongest evidence for linkage to bipolar disorder
BIPOLAR II DISORDER § Chromosome 18q derived largely from bipolar
- Bipolar disorder is a brain disorder that causes II-bipolar II sibling pairs and from families
shifts in mood, energy and activity levels, and the which probands had panic symptoms
capacity to carry out day-to-day tasks
- Characterized by mood swings - from being DIAGNOSIS AND CLINICAL FEATURES
excessively "up" exhilarated, and energized (known as - Specify the severity, frequency and duration of
manic episodes) to being extremely sad, "down" or hypomanic episode
despairing (known as depressive episodes) - Criteria for Hypomanic episode is listed together
- Bipolar 2 Disorder, sometimes misdiagnosed as with Bipolar II Disorder to decrease overdiagnosis of
depression, is a major depressive episode lasting at hypomanic episodes
least two weeks and a minimum of one hypomanic
episode that's less severe than a full-blown manic
episode
- Patients typically don't experience manic episodes
intense enough to require hospitalization

EPIDEMIOLOGY
- Lifetime prevalence: 0.3 - 4.8%
- Sex: equal prevalence
- Age: 5 - 50 y.o., (mean 30 y.o.)
- Marital Status: Divorced & Single
- Socioeconomic & Cultural Factors: upper economic
group and not graduates from college

E. YV. 9
Bipolar II Disorder 133

4. Flight of ideas or subjective experience that thoughts are racing.

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful conse-
quences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or
foolish business investments).
C. The episode is associated with an unequivocal change in functioning that is uncharac-
teristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupa-
tional functioning or to necessitate hospitalization. If there are psychotic features, the
episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication or other treatment).
Note: A full hypomanic episode that emerges during antidepressant treatment (e.g.,
medication, electroconvulsive therapy) but persists at a fully syndromal level beyond
the physiological effect of that treatment is sufficient evidence for a hypomanic episode
diagnosis. However, caution is indicated so that one or two symptoms (particularly in-
creased irritability, edginess, or agitation following antidepressant use) are not taken
as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bi-
polar diathesis.
Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2-week
period and represent a change from previous functioning; at least one of the symptoms
is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to a medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjec-
tive report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g.,
appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the
day, nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than
5% of body weight in a month), or decrease or increase in appetite nearly every
day. (Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day. MENTAL STATUS EXAMINATION
5. Psychomotor agitation or retardation nearly every day (observable by others; not
merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day. COMPONENT DEPRESSION HYPOMANIA
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delu-
sional) nearly every day (not merely self-reproach or guilt about being sick). GENERAL Psychomotor Psychomotor
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (ei-
ther by subjective account or as observed by others). APPEARANCE retardation agitation
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with-
out a specific plan, a suicide attempt, or a specific plan for committing suicide. MOOD, Depression Persistent
B. The symptoms cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning. AFFECT, elevated, expansive,
C.
134The episode is not attributable to the physiological effects of a and
Bipolar substance
RelatedorDisorders
another
medical condition. FEELINGS or irritable mood
Note: Criteria A–C above constitute a major depressive episode. Decreased rate Pressured speech
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a nat- SPEECH
ural disaster, a serious medical illness or disability) may include the feelings of intense sad- and volume
ness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion
A, which may resemble a depressive episode. Although such symptoms may be under- Hallucinations/
standable or considered appropriate to the loss, the presence of a major depressive episode PERCEPTUAL
in addition to the normal response to a significant loss should be carefully considered. This Delusions
decision inevitably requires the exercise of clinical judgment based on the individual’s history
and the cultural norms for the expression of distress in the context of loss.1
DISTURBANCE
Bipolar II Disorder
A. Criteria have been met for at least one hypomanic episode (Criteria A–F under “Hypo- Negative view of Flight of ideas
manic Episode” above) and at least one major depressive episode (Criteria A–C under
“Major Depressive Episode” above). THOUGHT the world and
B. There has never been a manic episode.
C. The occurrence of the hypomanic episode(s) and major depressive episode(s) is not themselves
better explained by schizoaffective disorder, schizophrenia, schizophreniform disor-
der, delusional disorder, or other specified or unspecified schizophrenia spectrum and SENSORIUM Oriented, impaired Distractibility
other psychotic disorder.
D. The symptoms of depression or the unpredictability caused by frequent alternation be- AND concentration
tween periods of depression and hypomania causes clinically significant distress or im-
pairment in social, occupational, or other important areas of functioning. COGNITION
Coding and Recording Procedures
Bipolar II disorder has one diagnostic code: 296.89 (F31.81). Its status with respect to cur-
IMPULSE Suicidal ideation, Excessive part in
rent severity, presence of psychotic features, course, and other specifiers cannot be
coded but should be indicated in writing (e.g., 296.89 [F31.81] bipolar II disorder, current
CONTROL commit suicide activities
episode depressed, moderate severity, with mixed features; 296.89 [F31.81] bipolar II dis-
order, most recent episode depressed, in partial remission). JUDGEMENT Assess by history
Specify current or most recent episode:
Hypomanic
AND INSIGHT and current state
Depressed
Overemphasize
Specify if: RELIABILITY
With anxious distress (p. 149) bad over good
With mixed features (pp. 149–150)

1
In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief
the predominant affect is feelings of emptiness and loss, while in a MDE it is persistent depressed
mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to
decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These
waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of a
E. YV.
MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may 10
be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhap-
 DIFFERENTIAL DIAGNOSIS TREATMENT

DDx Rule in Rule out

Unstable relationship, - Triggered by
impulsivity and interpersonal
Borderline
affective instability conflicts
Personality
- (+) suicidal or
Disorder
self-mutilating
behavior
Major depressive (-) hypomanic
- Hospitalization: indicated when patients appear to be
Major episode: depressed episodes
a danger for themselves or others
Depressive mood, lost of interest
- Mild depression or hypomania on the other hand can
Disorder or pleasure for at
be treated in the outpatient setting
least 2 weeks
- Pharmacology: divided into both acute and
Elevated mood, ↓ - At least one
maintenance phases; focuses on the symptomatic
need for sleep, flight manic episode
Bipolar I aspect (depression and hypomania), also involves the
of ideas, inflated self- - (+) psychotic
Disorder formulation of different strategies mania,
esteem, distractibility features
hypomania or depression
for at least a week
o Acute bipolar depression - antidepressants
(dopamine), selective serotonin reuptake
COURSE AND PROGNOSIS
inhibitors (SSRIs) and norepinephrine.
- Average age of onset is mid-20’s; can begin in late
o Hypomania (Acute Mania) - easy to treat as
adolescence and throughout adulthood
agents can be used alone or in combination to
- Childhood or Adolescent onset: More severe lifetime
bring down from a high; possible mood
course
stabilizers (Lithium carbonate, Carbamazepine
- With Rapid Cycling: 5-15% of individuals have >4
and Oxcarbazepine), Antimanics (Clonazepam,
mood episodes within 12 months; assoc. with poor
Lorazepam), and Atypical and Typical
prognosis
Antipsychotics, which are useful not only in
- Number of Hypomanic and Major Depressive episode
treating mania but may also be effective in
is higher
treating anxiety
- Interval between mood episodes decreases as
o Maintenance treatment - an important aspect
individual ages
to make sure a patient follows; Lithium,
- Risk and Prognostic Factors: Genetic, Physiological
carbamazepine, and valproic acid, alone or in
and Course modifiers
combination, are the most widely used agents in
o Risk tends to be highest among relative with
the long-term treatment
Bipolar II disorder
o Return to previous level of social function more
CASE
likely for younger individuals and with less
Mariah Carey, 52-year-old singer was first
severe depression
diagnosed with “Bipolar II Disorder” last 2001. She
o More education, fewer years of illness and being
verbalised “For a long time I thought I had a severe
married are independently associated with
sleep disorder, but it wasn't normal insomnia. I was
functional recovery in both bipolar types
irritable at work and in fear of letting people down. It
turns out that I was having manic episodes. There
were times I have very low energy, feeling sad and
isolated”. Mariah experienced panic attacks, which made

E. YV. 11
her feel worse about herself. She turned to alcohol and Coexisting Disorders
marijuana to alleviate what she was feeling. - Major depressive disorder
Mariah recalled becoming depressed after her - Anxiety disorders (panic)
divorce. These episodes involved a depressed mood, lack - Substance abuse
of energy, deep feelings of guilt, and some thoughts - Borderline personality disorder
that she wasn’t doing enough for her career. Mariah - Common with 1st-degree relatives with major
also sometimes had periods of “too much” energy, depressive disorder
irritability and racing thoughts where she would drown
herself in her career. These episodes of excess energy ETIOLOGY
could last hours, days or a couple of weeks. Biological Factors
- Sleep Studies: many exhibit 2 state markers for
DYSTHYMIA depression - decreased Rapid EM latency & increased
- A.k.a Persistent Depressive Disorder REM density
- Continuous but less severe depressed mood that - Neuroendocrine Studies
may last throughout the day for a period of at least o Adrenal Axis - tested using Dexamethasone
1 to 2 years Suppression Test, less likely to have abnormal
- Associated with the feelings of Inadequacy, Guilt, results
Irritability, Anger, Withdrawal from society, Loss of o Thyroid Axis - tested using TRH stimulation test
interest, Lack of productivity
- May also tend to withdraw from the society, lose Psychosocial Factors
interest and being less productive - Psychodynamic Theories: results from personality
- Before, it was known as depressive neurosis or and ego development, and this culminates in
neurotic depression difficulty in adapting to adolescence and young
o 1980, dysthymia was used which literally means adulthood
“ill humored” o Karl Abraham - conflicts of depression center on
- Unlike the major depressive order, patients used to oral- & anal-sadistic traits
complain that they have always been depressed § Anal traits are excessive orderliness, guild, &
- Most cases are early in onset, usually it started concern for others
during childhood or adolescent stage § Postulated to be a defense against
o Can also occur at late onset in older adults disorganization, preoccupation, and hostility
- Can occur as a secondary complication of other § Often have low self-esteem, anhedonia &
psychiatric disorders introversion à Depressive Character
- Refers to a subclinical depressive disorder with a o Sigmund Freud
low-grade chronicity for at least 2 years, insidious § Interpersonal disappointment early in life
onset, and persistent or intermittent course can cause a vulnerability to depression à
ambivalent love relationships as an adult
EPIDEMIOLOGY • Experience real or threatened losses in
Prevalence adult life then trigger depression
- Common to all; affects about 5-6% of the general § Persons susceptible to depression à orally
population dependent & require constant narcissistic
- affects about 1/2 or 1/3 of psychiatric patients gratification
- Women <64 years of age are highly prevalent than • Deprived of love, affection and care à
men at any age clinically depressed; experience a real loss
- Other factors: unmarried, young and with low
incomes

E. YV. 12
 à internalize/introject the lost object and DSM-V Criteria
turn anger on it, thus on themselves - Presence of a depressed mood most of the time for
- Cognitive Theory: Disparity between actual & at least 2 years (or 1 year for children and
fantasized situations leads to diminished self- adolescents)
esteem & sense of helplessness - Should have no symptoms that are better accounted
§ Successful cognitive therapy for as major depressive disorder
has provided some support to - No manic or hypomanic episodes
this theory - Early onset (before the age of 21) or late onset (after
the age of 21)
DIAGNOSIS AND CLINICAL FEATURES
- Clinical features overlaps with MDD, but Dysthymia
have a more subjective depression
o More symptoms than signs of depression
- Appetite and libido disturbances are uncharacteristic;
no presence of psychomotor agitation or retardation
- Inertia, lethargy, anhedonia that is worse in the
morning
- Best characterized as long-standing, fluctuating, low-
grade depression experienced as part of the habitual
self
- An accentuation of the traits in a depressive
temperament
- Anxiety not necessarily seen
- Essential Features: habitual gloom, brooding, lack of
joy in life, and preoccupation with inadequacy
- Often diagnosed in patients with anxiety and phobic
disorders; however, anxiety is not necessarily part of
the clinical picture
Dysthymic Variants
Attributes, Assets, and
- Common in patients with chronically disabling
Liabilities of Depressive
physical disorders, particularly among elderly
Temperaments
- Dysthymia-like, clinically significant subthreshold
Gloomy, incapable of fun, depression lasting 6 or more months has been
complaining
Humorless
described in neurological conditions (including stroke)
Pessimistic and given to brooding o Aggravates prognosis of underlying neurological
Guilt-prone, low self-esteem, and
preoccupied with inadequacy or disease, therefore deserves pharmacotherapy
failure - Persons with dysthymia presenting as adults tend
Introverted with restricted social Iife
Sluggish, living a life out of action to purse a chronic unipolar course
Few but constant interests o Rarely develops spontaneous hypomania or
Passive
mania; when treated with antidepressants à
Reliable, dependable, and devoted some may develop brief hypomanic switches à
disappear when dose is decreased

E. YV. 13
 DIFFERENTIAL DIAGNOSIS Cognitive Therapy
- Most clinical features can be present in other mood - Technique in which patients are taught new ways of
and psychiatric disorders, and some are clinically thinking
similar - Themselves, World, Future
- Less severe depressive symptoms - Short-term therapy: focuses on current problems
MINOR DEPRESSIVE
- Episodic nature and how to resolve them
DISORDER
- Euthymic mood
RECURRENT BRIEF - Brief periods (less than 2 weeks) Behavioral Therapy
DEPRESSIVE - Symptoms are more severe - Theory: Depression is caused by a loss of Positive
DISORDER - Episodic disorder reinforcement
- 40% of patients w/ major - Separation, Death, or Environmental change
depressive disorder also meet - Specific Goals
criteria for dysthymia o Increase Activity
- Poorer prognosis o Provide pleasant experiences
DOUBLE - Treatment should be directed o Teach patients how to relax
DEPRESSION towards both disorders - Altering Personal Behavior
o Resolution of symptoms of o Most effective way to change the associated
major depressive episodes depressed thought and feelings of depressed
leaves patient with significant patients
psychiatric impairment o Often used to treat px’s feeling of helplessness
- Patients with dysthymia tend to who seem to meet every life challenge with a
cope through substance abuse sense of impotence
ALCOHOL AND - Alcohol, cocaine, marijuana - Treat the learned helplessness of patients
SUBSTANCE ABUSE - Comorbid diagnosis: long-term use
can result to an identical clinical Insight-Oriented (Psychoanalytic) Psychotherapy
picture - Most common treatment
- Treatment of choice
PROGNOSIS - Relate the development and maintenance of
- 50% experience insidious onset before the age of 25 depressive symptoms and maladaptive personality
- Early onset - Inc. Risk for MDD (20%), Bipolar II (15%) features to unresolve conflict from early childhood
or Bipolar I (<5%) - Ambivalent current relationships (parents, friends
- Only 10 - 15% are in remission 1 year after diagnosis and others) in current life are examined
- 25% never attain complete recovery - Goal: patient’s understanding of how they try to
- Overall GOOD prognosis, even though the prognosis gratify excessive need for outside approval to
varies from patient to patient, treatment such as counter low-self esteem and a harsh super ego
antidepressants and psychotherapies have positive
effects Interpersonal Therapy
- Patient’s current interpersonal experiences and ways
TREATMENT of coping with stress are examined
- Combination of pharmacotherapy and some form of o Reduce depressive symptoms
psychotherapy may be the most effective treatment o Improve self-esteem
for this disorder - 12-16 weekly sessions with antidepressants

E. YV. 14
Family and Group Therapies
- May help both patient and patient’s family deal with
symptoms; esp. when a biologically based sub-
affective syndrome is present
- May help withdrawn patients learn new ways to
overcome interpersonal problems

Pharmacotherapy
- Many clinicians avoid prescribing antidepressants
because this is a psychologically determined disorder
- Studies have shown therapeutic success
- Selective serotonin reuptake inhibitors:
o Venlafaxine
o Bupropion
- Monoamine oxidase inhibitors

Hospitalization
- Not usually indicated
- Indications:
o Marked social or professional incapacitation
o Need for extensive diagnostic procedures
o Suicidal ideation

E. YV. 15