MOOD

DISORDERS
CC LEQUIGAN, DARLYN
 OUTLINE
1. Introduction 5. Clinical Features 9. Course & Prognosis

2. Epidemiology 6. Mental Status Exam 10. Treatment

Major Depressive
3. Etiology 7. Disorder

4. Comorbidity 8. Bipolar Disorder

01 INTRODUCTION
MOOD
Pervasive and sustained
emotion or feeling tone that
influences a person’s
behavior
 AFFECT
Expression of the mood that
appears to the clinician
 TYPES OF MOOD DISORDERS

Major
Depressive Cyclothymia
Disorder

Bipolar
Dysthymia
Disorder
 DEPRESSION
Marked diminished interest or pleasure
Persistent
Affect’s one relationship and mood
 MANIA HYPOMANIA
Persistent elevated, Persistent elevated,
expansive, irritable mood expansive, irritable mood
Increased goal-directed Increased goal-directed
activity activity
> 1 week > 4 days
Marked impairment in NO impairment in
functioning functioning
 DYSTHYMIA
At least 2 years of depressed mood
not sufficiently severe to fit MDD

CYCLOTHYMIA
At least 2 years of hypomanic episode
Not sufficiently meet criteria for BPD
02 EPIDEMIOLOGY
 INCIDENCE & PREVALENCE
Table 1. Lifetime Prevalence Rates of Depressive Disorders
 INCIDENCE & PREVALENCE
Table 2. Lifetime Prevalence Rates of Bipolar I Disorder, Bipolar I I Disorder,
Cyclothymic Disorder, and Hypomania
 SEX

<
Major Depressive Disorder
two fold greater prevalence of major
depressive disorder in women than in
men
 SEX

=
Bipolar 1 Disorder
Manic episodes Depressive episodes are
are more more common
common Mixed manic episodes
Rapid cyclers
 AGE
Bipolar I
Onset is earlier
Ranges from 5 or 6 years old to 50 years old
Mean age of 30 years old

Major depressive disorder

Mean age is 40
50% of onset between ages of 20 and 50 years
Increasing among <20 year olds.
 MARITAL STATUS
Major depressive disorder
Without close interpersonal relationship
Separated or divorced

Bipolar I disorder
Divorced
SIngle
SOCIOECONOMIC AND
CULTURAL FACTORS
MDD:
No correlation between socioeconomic status
More common in rural than urban areas

Bipolar I:
More common in those who did not graduate from
college
03 ETIOLOGY
 ETIOLOGIES
Biological Psychosocial
Factors Factors

Genetic Factors Other

Formulations of
Depression
 ETIOLOGIES
Monoamine Hypothesis
Alterations in Monoamine neurotransmitters BIOLOGICAL
Norepinephrine FACTORS
Downregulation of B-adrenergic receptors
and clinical antidepressant responses
Serotonin GENETIC FACTORS
Most commonly associated with depression
Depletion may precipitate depression
Dopamine
PSYCHOSOCIAL
Reduced in Depression
FACTORS
Increased in mania
Others
Acetylcholine OTHER
GABA FORMULATIONS OF
Glutamate DEPRESSION
 ETIOLOGIES
HPA Axis
BIOLOGICAL
Dysregulation FACTORS

Alteration of Hormonal Regulations

Elevated HPA activity GENETIC FACTORS
hallmark of mammalian stress responses
one of the clearest links between depression
and the biology of chronic stress. PSYCHOSOCIAL
Thyroid Axis Activity FACTORS
Growth Hormone
Prolactin
OTHER
FORMULATIONS OF
DEPRESSION
 ETIOLOGIES
Alterations of Sleep
BIOLOGICAL
Neurophysiology FACTORS

Depression is associated with a premature loss of GENETIC FACTORS

deep (slow-wave) sleep and an increase in nocturnal
arousal.
The latter is reflected by four types of disturbance: (1) PSYCHOSOCIAL
an increase in nocturnal awakenings, (2) a reduction FACTORS
in total sleep time, (3) increased phasic rapid eye
movement (REM) sleep, and (4) increased core body
temperature OTHER
FORMULATIONS OF
DEPRESSION
 04
Inflammation ETIOLOGIES
Increased IL-18, IL-2, IL-6; TNF-Alpha; CRPl PGE2
Positive feedback between depression and
inflammation BIOLOGICAL
FACTORS

Structural and Functional GENETIC FACTORS

Brain Imaging
PSYCHOSOCIAL
In depressive disorders, abnormal hyperintensities in FACTORS
subcortical regions, (periventricular regions, the basal
ganglia, and the thalamus) OTHER
In bipolar I disorder, hyperintensities appear to reflect FORMULATIONS OF
the deleterious neurodegenerative effects DEPRESSION
 ETIOLOGIES

GENETIC FACTORS
BIOLOGICAL
Family Studies FACTORS
1 depressed parent - 10-25% risk
Both depressed - double the risk
Bipolar History in the family
Greater risks for mood disorders GENETIC FACTORS
Unipolar depression - most common form
Twin Studies
Monozygotic - 70-90% PSYCHOSOCIAL
Dizygotic twins - 16-35% FACTORS
Linkage studies
→
Bipolar Chromosomes 18q and 22q
MDD → CREB1 on Chromosome 2 OTHER
Share a common degree of genetic underpinnings between FORMULATIONS OF
bipolar and MDD DEPRESSION
 ETIOLOGIES
PSYCHOSOCIAL
FACTORS BIOLOGICAL
FACTORS

Life Events & Environmental Factors

Losing a parent before age 11 years GENETIC FACTORS
Loss of spouse
Unemployment
Guilt
PSYCHOSOCIAL
FACTORS
Personality Factors
No single personality trait or type uniquely
predisposes a person to depression OTHER
OCD, Histrionic, and borderline → greater risk FORMULATIONS OF
DEPRESSION
 ETIOLOGIES
Psychodynamic
Factors in Depression BIOLOGICAL
FACTORS

Four key points (Freud and Abraham) GENETIC FACTORS

Disturbances in infant-mother relationship during
oral phase
Real or imagined object loss PSYCHOSOCIAL
Introjection of departed objectis FACTORS
Anger directed inward at self

OTHER
FORMULATIONS OF
DEPRESSION
 ETIOLOGIES
Psychodynamic
BIOLOGICAL
Factors in Mania FACTORS

Manic episodes as defense against underlying GENETIC FACTORS

depression
Abraham → inability to tolerate a developmental
tragedy
Bertram Lewin → ego overwhelm by pleasurable
PSYCHOSOCIAL
FACTORS
impulses
Klein→ defensive reaction to depression
OTHER
FORMULATIONS OF
DEPRESSION
 Cognitive Theory ETIOLOGIES

Results from a BIOLOGICAL

cognitive distortion FACTORS
present in person

Aaron Beck “Cognitive GENETIC FACTORS

Triad”
Views about self
Views about PSYCHOSOCIAL
environment FACTORS
Views about
future
OTHER
FORMULATIONS OF
DEPRESSION
 ETIOLOGIES

Learned Helplessness BIOLOGICAL

FACTORS
Theory
Connects depressive phenomena to the GENETIC FACTORS
experience of uncontrollable events
Outcomes were independent of responses
resulting to cognitive motivational and emotional PSYCHOSOCIAL
deficits FACTORS
Internal causal explanations produce a loss of self-
esteem after adverse external events
OTHER
FORMULATIONS OF
DEPRESSION
04 COMORBIDITY
Comorbidity
Increased risk of
alcohol abuse, panic disorder,
obsessive-compulsive disorder,
and social anxiety disorder
Both Unipolar and Bipolar Disorder
men more frequently present
with substance use disorders,
women more with comorbid
anxiety and eating disorders;
Bipolar
comorbidity of substance use and
anxiety disorders
 CLINICAL
05
FEATURES
Depressive Episodes
A depressed mood and a loss of interest or pleasure
Described as one of agonizing emotional pain
97% complain about reduced energy
80% complain of trouble sleeping,
Decreased appetite and weight loss
Some patients seem unaware of their depression
Two-thirds contemplate suicide, and 10 to 15 percent
commit suicide
 Depressive Episodes
Anxiety
Anxiety, alcohol abuse, and somatic complaints often
complicate treatment
Abnormal menses and decreased interest and
performance in sexual activities
Cognitive Symptoms
50% describe a diurnal variation in symptoms
Various changes in food intake and rest
 Depressive Episodes
Children and Adolescents
School phobia and excessive clinging to parents
Poor academic performance, substance abuse,
antisocial behavior, sexual promiscuity, truancy, and
running away
 Depressive Episodes
Older People
Correlated with low socioeconomic status, the loss of a
spouse, a concurrent physical illness, and social isolation
Appears more often with somatic complaints in older age
groups
Ageism may influence and cause clinicians to accept
depressive symptoms as normal in older patients
 Manic Episodes
An elevated, expansive, or irritable mood
The elevated mood is euphoric and often infectious
Alternatively mood may be irritable
Euphoria early in the course of the illness
Irritability In the later course

Inpatient treatment of manic patients can be complicated by

Their testing the limits of ward rules
Tendency to shift responsibility onto others
Exploitation of weakness of others
Propensity to create conflicts
Excessive alcohol drinking
 Manic Episodes
Pathological gambling
Tendency to disrobe in public places
Wearing unusual clothing and jewelry of bright colors
Inattention to small details
Impulsiveness, with a sense of conviction and purpose
Preoccupied by religious, political, financial, sexual, or persecutory
ideas that can evolve into complex delusional systems
Occasionally, manic patients become regressed
 Manic Episodes
Mania in Adolescents
Often misdiagnosed as antisocial personality disorder or schizophrenia
Psychosis
Alcohol or other substance abuse
Suicide attempts
Academic problems
Philosophical brooding
OCD symptoms
Multiple somatic complaints
Marked irritability
 Bipolar II Disorder
The clinical features of bipolar II disorder are those of
major depressive disorder combined with those of a
hypomanic episode
Associated with more marital disruption and with onset at an
earlier age than bipolar I disorder
At greater risk of both attempting and completing suicide
Coexisting Disorders
Anxiety
Alcohol dependence
Other substance-related disorders
Medical conditions
 MENTAL
06
STATUS EXAM
 General Description
Depression Mania
Generalized psychomotor Excited
Retardation Talkative
Psychomotor agitation Amusing
Stooped posture; Hyperactive
No spontaneous Grossly psychotic
movements; Disorganized
Downcast, averted gaze May require physical
restraints and sedation
 Mood, Affect and
Feelings
Depression Mania
Key symptom Euphoric
Deny depressive Irritable
feelings Low frustration tolerance
Don’t appear to be Emotionally labile
particularly
depressed
Social withdrawal
Decreased activity
 Speech
Depression Mania
Decreased rate Cannot be interrupted while
Decreased volume speaking
Short responses Intrusive nuisances
Delayed responses to Disturbed
questions Louder
Rapid
Difficult to interpret
Loose associations
Inability to concentrate
Flight of ideas
Incoherence
Perceptual Disturbance
Depression Mania
Delusions Delusions (75%)
Mood congruent vs Hallucinations
incongruent
Hallucinations
Psychotic depression
Mute, not bathing, soiling
(catatonic features)
 Thought
Depression Mania
Negative views of the Themes of self-
world and of confidence and self-
themselves aggrandizement
Non-delusional Easily distracted
ruminations about Unrestricted
loss, guilt, suicide, and Accelerated flow of ideas
death
Thought blocking
Profound poverty of
content
Sensorium and Cognition
Depression Mania
Oriented to person, Intact orientation and
place, and time memory
Depressive Delirious mania
pseudodementia
Impaired
concentration and
forgetfulness
 Impulse Control
Depression Mania
10-15% commit suicide Assaultive or threatening
Suicidal ideation Attempt suicide and
Occasionally consider homicide
killing a person
Lack of motivation or
energy to act in an
impulsive or violent
way
Judgement and Insight
Depression Mania
Hyperbolic Impaired judgment
Overemphasize their Little insight to their
symptoms, disorder, disorder
and life problems
 Reliability
Depression Mania
Overemphasize the Notoriously unreliable
bad and minimize the
good
 MAJOR
07 DEPRESSIVE
DISORDER
MAJOR DEPRESSIVE DISORDER
Mental Disorders
Substance-induced mood disorder must be ruled out
Determine if there are episodes of mania-like symptoms
Assess the severity and duration of the symptoms
Major: Complete depressive 2 weeks
Minor: Incomplete episodic depressive syndrome
Recurrent brief depressive disorder: Complete
depressive less than 2 wks
Dysthymic: incomplete depressive
MAJOR DEPRESSIVE DISORDER
Uncomplicated Bereavement
MDD
Morbid preoccupation of worthlessness;
Suicidal ideation;
Feelings that the person committed an act that
cause the spouse’s death,
Mummification, Severe anniversary reaction
Severe form of bereavement depression
Pines away, unable to live without the departed
person
Have a serious medical condition and their immune
fxn is often depressed
Clinically unwise to withhold antidepressant
Major Depressive Disorder
ONSET DURATION
~50% exhibited significant depressive Untreated: 6-13 mos
symptoms before the first identified Treated: 3 mos
episode
As the course progresses, tend to be
Before 40 y/o in 50% more frequent and longer

DEVELOPMENT OF MANIC EPISODES

5-10% of px initially dx with MDD develop manic episodes in
6-10 years

Mean age: 32 year or after 2-4 depressive episodes

Major Depressive Disorder
PROGNOSIS
Chronic and patient tends to relapse
50% of recovery in the first year, if patient was hospitalized for the 1st
episode
Recurrence after hospitalization:
First 6 mos: 25%
First 2 years: 30-50%
First 5 years: 50-70%
Lower rate in patients who continue prophylactic
psychopharmacological treatment and only 1 or 2 depressive episodes
Major Depressive Disorder
Good Prognostic Indicators
Mild episodes
Absence of psychotic symptoms
Short hospital stay
History of solid friendship
Stable family functioning
Sound social functioning within 5
years
Bad Prognostic Indicators
Coexisting dysthymic disorder
Alcohol and substance abuse
Anxiety disorder symptom
History of more than 1 depressive
episode
 BIPOLAR I
08
DISORDER
 BIPOLAR I DISORDER
DSM-5 Diagnostic Criteria for Bipolar I Disorder
For a diagnosis of bipolar I disorder, it is necessary to meet the following
criteria for a manic episode. The manic episode may have been preceded by
and may be followed by hypomanic or major depressive episodes.

Manic Episode
a. A distinct period of abnormally and persistently elevated, expansive,
or irritable mood and abnormally and persistently increased activity
or energy, lasting at least 1 week and present most of the day, nearly
every day (or any duration if hospitalization is necessary).
 BIPOLAR I DISORDER
DSM-5 Diagnostic Criteria for Bipolar I Disorder
Manic Episode
B. During the period of mood disturbance and increased energy or activity, three (or
more) of the following symptoms (four if the mood is only irritable) are present to a
significant degree and represent a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
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 (i .e., purposeless non-goal directed activity).
7. Excessive involvement in activities that have a high potential for painful consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business
investments)
 BIPOLAR I DISORDER
DSM-5 Diagnostic Criteria for Bipolar I Disorder
Manic Episode
a. 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 (or any duration if hospitalization is
necessary).
b. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only
irritable) are present to a significant degree and represent a noticeable change from usual behavior:

c. The mood disturbance is sufficiently severe to cause marked

impairment in social or occupational functioning or to necessitate
hospitalization to prevent harm to self or others, or there are psychotic
features.
 BIPOLAR I DISORDER
DSM-5 Diagnostic Criteria for Bipolar I Disorder
Manic Episode
a. 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 (or any duration if hospitalization is necessary).
b. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable)
are present to a significant degree and represent a noticeable change from usual behavior:
c. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent
harm to self or others, or there are psychotic features.

d. The episode is not attributable to the physiological effects of a substance

(e.g., a drug of abuse, a medication, other treatment) or to another
medical condition.
Note: A full manic 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 manic episode and therefore a bipolar I disorder.
Note: Criteria A to D constitute a manic episode. At least one lifetime
manic episode is required for the diagnosis of bipolar I disorder.
 BIPOLAR I DISORDER
DSM-5 Diagnostic Criteria for Bipolar I Disorder
Hypomanic Episode
a. A distinct period of abnormally and persistently elevated, expansive, or
irritable mood and abnormally and persistently increased activity or
energy, lasting at least 4 consecutive days and present most of the day,
nearly every day.
 BIPOLAR I DISORDER
DSM-5 Diagnostic Criteria for Bipolar I Disorder
Hypomanic Episode
a. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or
energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
b. During the period of mood disturbance and increased energy and activity, three (or more)
of the following symptoms (four if the mood is only irritable) have persisted, represent a
noticeable change from usual behavior, and have been present to a significant degree:
3. Inflated self-esteem or grandiosity.
4. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
5. More talkative than usual or pressure to keep talking.
6. Flight of ideas or subjective experience that thoughts are racing.
7. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli), as reported or observed.
8. Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation.
9. Excessive involvement in activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or
foolish business investments).
 BIPOLAR I DISORDER
DSM-5 Diagnostic Criteria for Bipolar I Disorder
Hypomanic Episode
a. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or
energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
b. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only
irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree.
c. The episode is associated with an unequivocal change in functioning that is
uncharacteristic 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
occupational functioning or to necessitate hospitalization. If there are psychotic
features, the episode is, by definition, manic.
 BIPOLAR I DISORDER
DSM-5 Diagnostic Criteria for Bipolar I Disorder
Hypomanic Episode
a. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least
4 consecutive days and present most of the day, nearly every day.
b. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have
persisted, represent a noticeable change from usual behavior, and have been present to a significant degree.
c. The episode is associated with an unequivocal change in functioning that is uncharacteristic 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 occupational 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, 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 increased irritability, edginess, or agitation
following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor
necessarily indicative of a bipolar diathesis.
Note: Criteria A-'F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I
disorder but are not required for the diagnosis of bipolar I disorder.
 BIPOLAR I DISORDER
DSM-5 Diagnostic Criteria for Bipolar I Disorder
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 another medical
condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective 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).
 BIPOLAR I DISORDER
DSM-5 Diagnostic Criteria for Bipolar I Disorder
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 another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective 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.
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.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly
every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by
subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide.
 BIPOLAR I DISORDER
DSM-5 Diagnostic Criteria for Bipolar I Disorder
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.
b. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
c. The episode is not attributable to the physiological effects of a substance or another
medical condition.
Note: Criteria A-C constitute a major depressive episode. Major depressive episodes are common in bipolar I disorder
but are not required for the diagnosis of bipolar I disorder.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious
medical illness or disability) may include the feelings of intense sadness, 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 understandable or considered appropriate to the loss, the presence of a major depressive episode in
addition to the normal response to a significant loss should also be carefully considered. This 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.
 BIPOLAR I DISORDER
DSM-5 Diagnostic Criteria for Bipolar I Disorder

a. Criteria have been met for at least one manic episode (Criteria A-D under
“Manic Episode”).
b. The occurrence of the manic and major depressive episode(s) is not better
explained by schizoaffective disorder, schizophrenia, schizophreniform
disorder, delusional disorder, or other specified or unspecified schizophrenia
spectrum and other psychotic disorder.
 BIPOLAR I DISORDER
DSM-5 Diagnostic Criteria for Bipolar I Disorder
Coding & Recording Procedures
 BIPOLAR I DISORDER
DSM-5 Diagnostic Criteria for Bipolar I Disorder
Coding & Recording Procedures
 BIPOLAR I DISORDER
DSM-5 Diagnostic Criteria for Bipolar I Disorder
Bipolar I Disorder, Single Manic Episode
First manic episode
first episode of bipolar I disorder depression cannot be distinguished
from patients with major depressive disorder.

Bipolar I Disorder, Recurrent

Manic episodes are considered distinct when they are separated by at
least 2 months without significant symptoms of mania or hypomania.
Bipolar I Disorder:
Differential
Diagnosis
Differential Diagnosis
Depressive
Episode
same as that for a patient being
considered for a diagnosis of major
depressive disorder
Manic Episode
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
Mood Disorder
Caused by a general medical
condition
Substance-induced
Borderline, narcissistic,
histrionic, and antisocial
personality disorders
MDD vs BIPOLAR DISORDER
Clinical features Predictive of Bipolar Disorder
Early age at onset
Psychotic depression before 25 years of age
Postpartum depression, especially one with psychotic
features
Rapid onset and offset of depressive episodes of short
duration (<3 months)
Recurrent depression (>5 episodes)
Depression with marked psychomotor retardation
Atypical features (reverse vegetative signs)
Seasonality
MDD vs BIPOLAR DISORDER
Clinical features Predictive of Bipolar Disorder
Bipolar family history
High-density, three-generation pedigrees
Trait mood lability (cyclothymia)
Hyperthymic temperament
Hypomania associated with antidepressants
Repeated (at least 3x) loss of efficacy of
antidepressants after initial response
Depressive mixed state (with psychomotor
excitement, irritable hostility, racing thoughts, and
sexual arousal during major depression)
 Bipolar I Disorder
ONSET
Most experience both
depressive and manic
episodes
Often starts with depression
and is recurring
10-20% only manic episodes
Rapid onset but may
evolve over weeks
DURATION
Untreated manic episode: 3
months
90% with single manic episodes
are likely to have another
INTEREPISODE INTERVAL
Decreases as the disease
progresses
Stabilizes at 6-9 months
 Bipolar I Disorder
PROGNOSIS
Poorer compared to MDD
40-50% with Bipolar I have second manic episode
within 2 years
Only 50-60% achieve significant control of
symptoms with Lithium
7% no recurrence of symptoms
45% more than one episode
40% chronic episode
 Bipolar I Disorder
Good Prognostic Poor Prognostic Indicators
Indicators Male gender
Short duration of manic Early onset
episodes Premorbid poor
Advanced age of onset occupational status
Few suicidal thoughts Alcohol dependence
Few coexisting Psychotic features
psychiatric/medical Depressive features
problems Interepisode depressive
features
 Bipolar I Disorder
PROGNOSIS
15% are well
45% are well but have multiple relapses
30% are in partial remission
10% are chronically ill
 BIPOLAR II
09
DISORDER
 BIPOLAR II DISORDER
DSM-5 Diagnostic Criteria for Bipolar II Disorder
For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for
a current or past hypomanic episode and the following criteria for a current or past
major depressive episode:

Hypomanic Episode
a. A distinct period of abnormally and persistently elevated, expansive, or
irritable mood and abnormally and persistently increased activity or
energy, lasting at least 4 consecutive days and present most of the day,
nearly every day.
 BIPOLAR II DISORDER
DSM-5 Diagnostic Criteria for Bipolar II Disorder
Hypomanic Episode
a. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy,
lasting at least 4 consecutive days and present most of the day, nearly every day.
b. During the period of mood disturbance and increased energy and activity, three
(or more) of the following symptoms (four if the mood is only irritable) have
persisted, represent a noticeable change from usual behavior, and have been
present to a significant degree:
3. Inflated self-esteem or grandiosity.
4. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
5. More talkative than usual or pressure to keep talking.
6. Flight of ideas or subjective experience that thoughts are racing.
7. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as
reported or observed.
8. Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation.
9. Excessive involvement in activities that have a high potential for painful consequences (e.g.,
engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
 BIPOLAR II DISORDER
DSM-5 Diagnostic Criteria for Bipolar II Disorder
Hypomanic Episode
a. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least
4 consecutive days and present most of the day, nearly every day.
b. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have
persisted, represent a noticeable change from usual behavior, and have been present to a significant degree.

c. The episode is associated with an unequivocal change in

functioning that is uncharacteristic 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 occupational functioning or to necessitate hospitalization.
If there are psychotic features, the episode is, by definition, manic.
 BIPOLAR II DISORDER
DSM-5 Diagnostic Criteria for Bipolar II Disorder
Hypomanic Episode
a. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least
4 consecutive days and present most of the day, nearly every day.
b. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have
persisted, represent a noticeable change from usual behavior, and have been present to a significant degree.
c. The episode is associated with an unequivocal change in functioning that is uncharacteristic 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 occupational 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, other treatment) or
another medical condition.
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
increased irritability, edginess, or agitation following antidepressant use) are not taken as
sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar
diathesis.
 BIPOLAR II DISORDER
DSM-5 Diagnostic Criteria for Bipolar II Disorder
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 another medical
condition.
1. Depressed mood most of the day, nearly every day, as indicated by either
subjective 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).
 BIPOLAR II DISORDER
DSM-5 Diagnostic Criteria for Bipolar II Disorder
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 another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective 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.
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.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by
subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide.
 BIPOLAR II DISORDER
DSM-5 Diagnostic Criteria for Bipolar II Disorder
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.
b. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
c. The episode is not attributable to the physiological effects of a substance
or another medical condition.
Note: Criteria A-C constitute a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural
disaster, a serious medical illness or disability) may include the feelings of intense sadness,
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 understandable or
considered appropriate to the loss, the presence of a major depressive episode in addition to the
normal response to a significant loss should also be carefully considered. This 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.
 BIPOLAR II DISORDER
DSM-5 Diagnostic Criteria for Bipolar II Disorder
a. Criteria have been met for at least one hypomanic episode (Criteria A-F under
“Hypomanic Episode”) and at least one major depressive episode (Criteria A-C
under “Major Depressive Episode”).
b. There has never been a manic episode.
c. The occurrence of the hypomanic episode(s) and major depressive episode(s)
is not better explained by schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional disorder, or other specified or
unspecified schizophrenia spectrum and other psychotic disorder.
d. The symptoms of depression or the unpredictability caused by frequent
alternation between periods of depression and hypomania causes clinically
significant distress or impairment in social, occupational, or other important
areas of functioning.
 BIPOLAR II DISORDER
DSM-5 Diagnostic Criteria for Bipolar II Disorder
Coding & Recording Procedures
Diagnostic Code: 296.89 (F31.81 )
Its status with respect to current 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 episode
depressed, moderate severity, with mixed features;
296.89 [F31.81] bipolar II disorder, most recent episode
depressed, in partial remission).
Specify current or most recent episode:
Hypomanic
Depressed
 BIPOLAR II DISORDER
DSM-5 Diagnostic Criteria for Bipolar II Disorder
Coding & Recording Procedures
Specify if:
With anxious distress
With mixed features
With rapid cycling
With mood-congruent psychotic features
With mood-incongruent psychotic features
With catatonia. Coding note: Use additional code 293.89 (F06.1).
With péripartum onset
With seasonal pattern: Applies only to the pattern of major
depressive episodes.
 BIPOLAR II DISORDER
DSM-5 Diagnostic Criteria for Bipolar II Disorder
Coding & Recording Procedures

Specify course if full criteria for a mood episode are not currently
met:
in partial remission
In full remission
Specify severity if full criteria for a mood episode are currently met:
Mild
Moderate
Severe
Differential Diagnosis
Other mood disorders
Psychotic disorders
Borderline disorder
often have a severely disrupted life

MDD vs Bipolar I Disorder vs Bipolar II

Disorder
clinical evaluation of the mania-like
episodes
 BIPOLAR II DISORDER
COURSE & PROGNOSIS
Diagnosis is stable
High likelihood that patients with bipolar II disorder will have
same diagnosis 5 years later
Chronic disease that warrants long-term treatment strategies
10 TREATMENT
 GENERAL
Goals of Treatment
Patient's safety
Complete diagnostic evaluation of the patient
A treatment plan that addresses not only the
immediate symptoms but also the patient's
prospective well-being
 HOSPITALIZATION
Indications for Hospitalization
Risk of suicide or homicide
A patient's grossly reduced ability to get food and shelter
Need for diagnostic procedures
A history of rapidly progressing symptoms
Rupture of a patient's usual support systems
PSYCHOSOCIAL THERAPY
Cognitive therapy
Interpersonal Therapy
Behavior Therapy
Psychoanalytically Oriented Therapy
Family Therapy
PSYCHOSOCIAL THERAPY
COGNITIVE THERAPY
Goals:
Alleviate depressive episodes and prevent their
recurrence
Develop alternative, flexible, and positive ways of thinking
Rehearse new cognitive and behavioral responses.
PSYCHOSOCIAL THERAPY
INTERPERSONAL THERAPY
This therapy is based on two assumptions.
Current interpersonal problems are likely:
to have their roots in early dysfunctional
relationships.
to be involved in precipitating or perpetuating the
current depressive symptoms.
This therapy usually consists of 12 to 16 weekly sessions
and is characterized by an active therapeutic approach.
PSYCHOSOCIAL THERAPY
BEHAVIOR THERAPY
Addresses maladaptive behaviors in therapy
Patients will learn to function in the world in such a way
that they receive positive reinforcement.
PSYCHOSOCIAL THERAPY
PSYCHOANALYTICALLY ORIENTED THERAPY
Goals:
To effect a change in a patient's personality structure or
character
Improvements in interpersonal trust, capacity for
intimacy, coping mechanisms, the capacity to grieve
Ability to experience a wide range of emotions
PSYCHOSOCIAL THERAPY
FAMILY THERAPY
Family therapy examines the role of the mood-disordered
member in the overall psychological well-being of the
whole family

INDICATIONS:
The disorder jeopardizes a patient's marriage or
family functioning
Mood disorder is promoted or maintained by the
family situation.
VAGAL NERVE STIMULATION
Studies have shown that a
number of patients with chronic,
recurrent major depressive
disorder went into remission
when treated with VNS
Use of left vagal nerve
stimulation (VNS) using an
electronic device implanted in
the skin
The mechanism of action of
VNS to account for
improvement is unknown
 TRANSCRANIAL
MAGNETIC STIMULATION
It involves the use of very short
pulses of magnetic energy to
stimulate nerve cells in the brain
Indication:
Treatment of depression in
adult patients who have
failed to achieve
satisfactory improvement
from one prior
antidepressant medication
SLEEP DEPRIVATION
Principle: Sleep deprivation temporarily relieve depression
in those who have unipolar depression.
Methods used may include:
Serial total sleep deprivation with a day or two of
normal sleep in between
Partial sleep deprivation - patients may stay awake
from 2 AM to 10 PM daily
Sleep deprivation with pharmacological treatment of
depression
 PHOTOTHERAPY
Indication:
patients who experience seasonal depression and
sleep disorders.
Involves exposing the affected patient to bright light in
the range of 1 ,500 to 10,000 lux or more typically with a
light box that sits on a table or desk.
Patients sit in front of the box for approximately 1 to 2
hours before dawn each day or after dusk.
PHARMACOTHERAPY
Accurate diagnosis is crucial because unipolar and
bipolar spectrum disorders require different treatment
regimens.
Objective:
Symptom remission, not just symptom reduction.
 PHARMACOTHERAPY
MAJOR DEPRESSIVE DISORDER
GENERAL CLINICAL GUIDELINES

Dosage of an antidepressant should be raised to the

maximum recommended level and maintained at that
level for at least 4 or 5 weeks.
Choice of antidepressants is determined by:
side effect profile least objectionable to a given
patient's physical status, temperament, and lifestyle.
PHARMACOTHERAPY
PHARMACOTHERAPY
PHARMACOTHERAPY
 PHARMACOTHERAPY
MAJOR DEPRESSIVE DISORDER
DURATION AND PROPHYLAXIS

Treatment
maintained for at least 6 months or the length of a
previous episode, whichever is greater.
Prophylactic treatment
effective in reducing the number and severity of
recurrences.
Maintenance Treatment
Only in patients with recurrent or chronic depressions
Treatment stopped
drug dose should be tapered gradually over 1 to 2 weeks
 PHARMACOTHERAPY
MAJOR DEPRESSIVE DISORDER
INITIAL MEDICATION SELECTION

Chronicity of the condition

Course of illness
Family history of illness and treatment response
Symptom severity
Concurrent general medical or other psychiatric conditions
Prior treatment responses to other acute phase treatments
Potential drug-drug interactions
Patient preference
 PHARMACOTHERAPY
MAJOR DEPRESSIVE DISORDER
TREATMENT OF DEPRESSIVE SUBTYPES

Major depressive disorder with atypical features -

preferentially respond to treatment with MAOis or SSRis.
Melancholic depressions - greater efficacy of
antidepressants with dual action on both serotonergic and
noradrenergic receptors.
Seasonal winter depression - light therapy major depressive
episodes with psychotic features - antidepressant and an
atypical antipsychotic or ECT.
 PHARMACOTHERAPY
MAJOR DEPRESSIVE DISORDER
COMORBID DISORDERS

The concurrent presence of another disorder can affect

initial treatment selection.
In general, the non-mood disorder dictates the choice of
treatment in comorbid states.
 PHARMACOTHERAPY
MAJOR DEPRESSIVE DISORDER
THERAPEUTIC USE OF SIDE EFFECTS

Choosing more sedating antidepressants for more anxious,

depressed patients or more activating agents for more
psychomotor-retarded patients is not generally helpful.
A patient's prior treatment history is important because an
earlier response typically predicts current response.
The history of a first-degree relative responding to a
particular drug is associated with a good response to the
same class of agents.
 PHARMACOTHERAPY
MAJOR DEPRESSIVE DISORDER
ACUTE TREATMENT FAILURES

Patients may not respond to a medication, because:

They cannot tolerate the side effects, even in the face of
a good clinical response
An idiosyncratic adverse event may occur
The clinical response is not adequate
The wrong diagnosis has been made.
Acute phase medication trials should last 4 to 6 weeks
Indication for treatment change:
Lack of a partial response by 4 to 6 weeks
 PHARMACOTHERAPY
MAJOR DEPRESSIVE DISORDER
SELECTING SECOND TREATMENT OPTIONS

When the initial treatment is unsuccessful, switching to an

alternative treatment or augmenting the current treatment is
a common option.
The decision to switch to a new single treatment rests on:
patient's prior treatment history
degree of benefit achieved with the initial treatment
patient preference.
 PHARMACOTHERAPY
MAJOR DEPRESSIVE DISORDER
SELECTING SECOND TREATMENT OPTIONS

Augmentation strategies are helpful with patients who have

gained some benefit from the initial treatment but who have
not achieved remission.
As a rule, switching rather than augmenting is preferred
after an initial medication failure.
 PHARMACOTHERAPY
MAJOR DEPRESSIVE DISORDER
COMBINED TREATMENT

Combination of medication and formal psychotherapy

for chronically depressed outpatients have shown a
higher response and higher remission rates for the
combination of pharmacotherapy and psychotherapy
than for either treatment used alone.
PHARMACOTHERAPY
BIPOLAR DISORDERS

The pharmacological treatment of bipolar disorders is

divided into both acute and maintenance phases.
Each of the medications is associated with a unique side
effect and safety profile, and no one drug is predictably
effective for all patients.
 PHARMACOTHERAPY
BIPOLAR DISORDERS
TREATMENT OF ACUTE MANIA

These agents can be used alone or in combination to

bring the patient down from a high.
Lithium carbonate
Anticonvulsants (e.g., Valproate, Carbamazepine,
Oxcarbazepine)
Benzodiazepine (e.g., clonazepam, lorazepam)
Atypical antipsychotics (e.g., risperidone, olanzapine)
or typical antipsychotics (e.g., haloperidol)
 PHARMACOTHERAPY
BIPOLAR DISORDERS
TREATMENT OF ACUTE BIPOLAR DEPRESSION

Antidepressant drugs are often enhanced by a mood

stabilizer in the first-line treatment for a first or isolated
episode of bipolar depression.
A fixed combination of olanzapine and fluoxetine
(Symbyax)
Bipolar patients in the depressed phase who do not
respond to treatment with standard antidepressants may
benefit with lamotrigine or low-dose ziprasidone (20 to 80
mg per day).
 PHARMACOTHERAPY
BIPOLAR DISORDERS
TREATMENT OF ACUTE BIPOLAR DEPRESSION

Electroconvulsive therapy can be used to those who do

not respond to lithium or other mood stabilizers,
especially in cases of intense suicidal tendency.
 PHARMACOTHERAPY
BIPOLAR DISORDERS
MAINTENANCE TREATMENT OF BIPOLAR DISORDER

Most widely used agents for long-term treatment:

Lithium
Carbamazepine
Valproic acid
Thyroid supplementation is frequently necessary during long-
term treatment.
Causes: lithium induced hypothyroidism, idiopathic thyroid
dysfunction among bipolar patients.
T3 (25 to 50 μg per day) is recommended for acute
augmentation strategies
T4 is frequently used for long-term maintenance
TAKE HOME MESSAGE
11 DYSTHYMIA
 Dysthymia
1. The most typical features of dysthymia, also known as
persistent depressive disorder, is the presence of a
depressed mood that lasts most of the day and is present
almost continuously.
2. There are associated feelings of inadequacy, guilt,
irritability, and anger; withdrawal from society; loss of
interest; and inactivity and lack of productivity
 Dysthymia
1980 Means “ill humored”

Before Depressive neurosis (also called Neurotic

depression)
 Dysthymia
Core Features

Low-grade chronicity for at least 2

years;
Insidious onset, with origin often in
childhood or adolescence
A persistent or intermittent course
 Epidemiology
Affects 5 to 6 percent of all persons.
1/3 – 1/2 of patients in general psychiatric clinics
The disorder is more common in women younger than 64
years of age than in men of any age
Unmarried
Young persons
First-degree relatives with major depressive disorder
 Epidemiology
COEXISTS WITH OTHER DISORDERS
Major depressive disorder
Anxiety disorders (especially panic disorder)
Substance abuse
Borderline personality disorder.
Likely to be taking a wide range of psychiatric medications
Etiology
BIOLOGICAL FACTORS

Sleep Studies Neuroendocrine Studies

Decreased rapid eye
Adrenal axis
movement (REM) latency
Thyroid axis
Increased REM density
 Etiology
PSYCHOSOCIAL FACTORS

Disorder results from personality and ego development and

culminates in difficulty adapting to adolescence and young
adulthood

Karl Abraham
Conflicts of depression center on oral- and anal-
sadistic traits.
Anal traits include excessive orderliness, guilt, and
concern for others
Defense against preoccupation with anal matter
and with disorganization hostility, and self-
preoccupation.
 Etiology
PSYCHOSOCIAL FACTORS

A major defense mechanism used is reaction

formation.
Low self-esteem, anhedonia, and introversion
are often associated with the depressive
character.
 Etiology
PSYCHOSOCIAL FACTORS

Freud
Interpersonal disappointment early in life can
cause a vulnerability to depression that leads to
ambivalent love relationships as an adult
Real or threatened losses in adult life then trigger
depression.
Persons susceptible to depression are orally
dependent and require constant narcissistic
gratification.
 Etiology
PSYCHOSOCIAL FACTORS

Cognitive Theory

It holds that a disparity between actual and

fantasized situations leads to diminished self-
esteem and a sense of helplessness.
Diagnosis & Clinical
Features
Diagnosis & Clinical
Features
Diagnosis & Clinical
Features
Diagnosis & Clinical Features
Dysthymia then is best
characterized as long-
standing, fluctuating,
low-grade depression,
experienced as part of
the habitual self and
representing an
accentuation of traits
observed in the
depressive
temperament.
Diagnosis & Clinical Features
DYSTHYMIC VARIANTS
Common in patients with chronically disabling physical
disorders, particularly among elderly adults.
Dysthymia-like, clinically significant, subthreshold
depression lasting 6 or more months has also been
described in neurological conditions, including stroke.
Persons with dysthymia presenting clinically as adults tend
to pursue a chronic unipolar course
 Differential Diagnosis
MINOR DEPRESSIVE DISORDER
Minor depressive disorder is characterized by episodes
of depressive symptoms that are less severe than
those seen in major depressive disorder.
Difference: Episodic nature of Minor DD, Euthymic
mood between episodes
 Differential Diagnosis
RECURRENT BRIEF DEPRESSIVE DISORDER
Recurrent brief depressive disorder is characterized by
brief periods (less than 2 weeks) during which
depressive episodes are present.
Difference: Episodic disorder, and their symptoms are
more severe
 Differential Diagnosis
DOUBLE DEPRESSION
MDD + Dysthymia

ALCOHOL AND SUBSTANCE ABUSE

Patients with dysthymia tend to develop coping
methods for their chronically depressed state that
involve substance abuse.
 Course & Prognosis
50% Insidious onset of symptoms before age 25 years
Despite the early onset, patients often suffer for a decade
before seeking psychiatric help and may consider early-
onset dysthymia simply part of life.

Dysthymia can progress to:

20% Major depressive disorder,
15% Bipolar II disorder,
<5 % Bipolar I disorder
10-15% Are in remission after 1 year of dx (with
antidepressants and psychotherapies)
25% No complete recovery
 Treatment
Options: Cognitive therapy, Behavior
therapy, and Pharmacotherapy
The combination of
pharmacotherapy and some form
of psychotherapy may be the
most effective treatment for the
disorder.
 Treatment
Cognitive Therapy
A technique in which patients are taught new ways of
thinking and behaving to replace faulty negative
attitudes about themselves, the world, and the future.

Behavior Therapy
Treatment methods focus on specific goals to
increase activity, to provide pleasant experiences, and
to teach patients how to relax.
 Treatment
Insight-Oriented (Psychoanalytic) Psychotherapy
Most common treatment method for dysthymia, and
many clinicians consider it the treatment of choice.

Interpersonal Therapy
Family and Group Therapies
 Treatment
Pharmacotherapy
Many clinicians avoid prescribing antidepressants for
patients; however, many studies have shown therapeutic
success with antidepressants.
Selective serotonin reuptake inhibitors (SSRIs) -
venlafaxine and bupropion
Monoamine oxidase inhibitors (MAOIs)

Hospitalization
Hospitalization is usually not indicated for patients with
dysthymia, but particularly severe symptoms, marked
social or professional incapacitation, the need for
extensive diagnostic procedures, and suicidal ideation are
all indications for hospitalization.
12 CYCLOTHYMIA
 Epidemiology
3 to 5% of all psychiatric outpatients, perhaps
particularly those with significant complaints about
marital and interpersonal difficulties.
1% Lifetime prevalence in the general population
Frequently coexists with borderline personality disorder.
Female-to-Male ratio 3:2
50 to 75% Have an onset between ages 15 and 25 years.
Often contain members with substance-related
disorder
 Etiology
Biological Factors
Positive family histories for bipolar I disorder
One-third of patients with cyclothymic disorder
subsequently have major mood disorders, that they
are particularly sensitive to antidepressant-induced
hypomania, and that about 60 percent respond to
lithium add further support to the idea of
cyclothymic disorder as a mild or attenuated form
of bipolar II disorder.
 Etiology
Psychosocial Factors

Most psychodynamic theories postulate that the

development of cyclothymic disorder lies in
traumas and fixations during the oral stage of
infant development.
Freud hypothesized that the cyclothymic state is
the ego’s attempt to overcome a harsh and
punitive superego.
 Clinical Features
Identical to the symptoms of bipolar II disorder except that
they are generally less severe
Depression as their major symptom, and these patients are
most likely to seek psychiatric help while depressed.
Primarily hypomanic symptoms and are less likely to consult
a psychiatrist than are primarily depressed patients.
Almost all patients with cyclothymic disorder have periods
of mixed symptoms with marked irritability.
Diagnostic Criteria
Differential Diagnosis
Possible medical and substance-related causes of
depression and mania
Borderline, antisocial, histrionic, and narcissistic
personality disorders
Attention-deficit/hyperactivity disorder (ADHD)
Course and Prognosis
Sensitive, hyperactive, or moody as young children.
Onset of frank symptoms occurs insidiously in the
teens or early 20s. The emergence of symptoms at
that time hinders.
About one-third of all patients with cyclothymic
disorder develop a major mood disorder, most often
bipolar II disorder.
 Treatment
Biological Therapy
The mood stabilizers and antimanic drugs are the
first line of treatment for patients with cyclothymic
disorder.
Although the experimental data are limited to
studies with lithium, other antimanic agents
For example, carbamazepine and valproate
(Depakene)-are reported to be effective
 Treatment
Psychosocial Therapy
Increasing patients' awareness of their condition
Helping them develop coping mechanisms for
their mood swings.
Because of the long-term nature of cyclothymic
disorder, patients often require lifelong treatment.
Family and group therapies may be supportive,
educational, and therapeutic for patients and for
those involved in their lives
 References

Sadock, B., Sadock, V., & Ruiz, P. (2015). Synopsis of Psychiatry (11th
ed.). Wolters Kluwer.
American Psychiatric Publishing. (2013). Diagnostic and statistical
manual of mental disorders (5th ed.).
THANK YOU!