Mood Disorders (affective disorders)

Mood Disorders (affective disorders)

What is a mood disorder? Mood is a person’s subjective emotional state
Affect – pattern of the observable (objective) behaviours e.g. facial expressions that are associated with subjective feelings, like mood Mood disorders involve a depression or elevation of mood as the primary disturbance In psychiatric classification, but only in classification, these two terms “Mood Disorders” and “Affective Disorders” mean the same. Mood is a subjective personal feeling, whereas the term “affect” describes objective manifestations of the mood what we see especially at the facial expression. The term “Mood Disorders” better than “Affective Disorders” explains the different kinds of illnesses we are dealing with and refers to the group of disorders when as the name implies, the main problem is within individual’s mood. Mood disorders according to our classification involve problems not only with lower mood that is depression but as well problems with elevated mood. When we describe patient’ s mental state we separately asses his or her mood, and separately his or her affect.

Types of mood disorders
Depressive Disorders Bipolar Disorders And there are basically two main categories of mood disorders. There is the Depressive Disorders in which the main symptom we have to do is depression, and Bipolar Disorders with symptoms not only of depression but also of elevated mood named mania or hypomania.

Unipolar Depression Depressed Mood – Depression

Bipolar Disorder Elevated Mood – Mania (Manic Phase)
Depressed Mood – Depression

PRIMARY Depressive Bipolar SECONDARY: Adjustment Mood Disorder This clasification could be also presented as a diagram. Substance- Induced Mood Disorder Mood Disorder Due to General Medical Condition

Types of Mood Disorders
Depressive Disorders Depressive Disorder NOS (Not Other Specified) Major Depressive Disorder MDD (Unipolar Depression) Dysthymic Disorder (Dysthymia) This is subclasification of Depressive Disorders MDD is called sometimes unipolar depression in contrast to depression in bipolar disorder – which we sometimes called bipolar depression. When I talk to you about clinical depression it means that I am describing the Major Depressive Episode. The term Episode would seem something short, but it only means that is a phenomenon that has it beggining and the end Major Depressive Episode Reccurent

Major Depressive Episode
Depressed mood or Anhedonia (loss of interest and pleasure) Depression is associated with many different types of symptoms that can result in different presentation in any given person. 1/ One of major symptoms is depressed mood . The other possibility if depressed mood is not present, is something called anhedonia what means inability in experience pleasure in activities that normally give one’s pleasure. One common example are parents who suddenly don’t enjoy spending time with their children but it can be any activity that people used to enjoy and no longer drive any pleasure for. Loss of sexual interest and desire is also common which can lead to problems in relationships.

Depressed mood or Anhedonia (loss of interest and pleasure) Persistently decreased sleep (early, middle, late insomnia) or increased sleep (atypical symptom) if only sleep problems CONSIDER „masked depression” 2/One of the most common physical symptoms is the sleep disturbance, most characteristically this is early morning awakening, so patients wake up in the early morning and not be able to go sleep again but still don’t go out of bed (it is called terminal late? insomnia). Restless sleep and frequent waking during the night (middle insomnia) is also common. Difficulty with falling asleep at the beginning of the night (early or initial insomnia) is usually seen when the anxiety also is present. The anxious patient is worrying a lot about many minor things, what causes problems with falling asleep In contrast hypersomnia or oversleeping also can be symptoms of depression, called than as atypical ones. They very often evidence that we have bipolar depression Sometimes we have the situations when the patient complains only for sleep problems and only experienced psychiatrist can detect other depressive symptoms which are not so evident. This kind of deperession we call masked depression what means that depression is „hidden” behind the mask of sleep problems.

Depressed mood or Anhedonia (loss of interest and pleasure) Persistently decreased (early, middle, late insomnia) or increased (atypical symptom) sleep if only sleep problems consider „masked depression” Feelings of worthlessness or inappropriate guilt (severe depression  delusions of guilt) Low energy or fatigue (↓ hygene, ↓ grooming) ( severe cases- „leaden paralysis”) Decreased concentration or indecisiveness, memory complaints  greatly impair work function (eldery patients- false diagnosis of dementia) Decrease or increase (atypical) in appetite OR significant weight loss or gain Psychomotor changes (retardation or agitation) Psychomotor changes which are subjective changes in motor function without objective abnormalities, are commonly seen in depression. Psychomotor retardation consists of slowing. This means slowed body movement, lack of facial expression, delayed speech response. But anxiety can be also present as psychomotor agitation. This means talking quickly, pacing, restlessness, inability to sit still. Racing thoughts can be symptoms of mania, but can also indicate anxiety.

Depressed mood or Anhedonia (loss of interest and pleasure) Persistently decreased (early, middle, late insomnia) or increased (atypical symptom) sleep if only sleep problems „masked depression” Feelings of worthlessness or inappropriate guilt (severe depression  delusions of guilt) Low energy or fatigue (↓ hygene, ↓ grooming) ( severe cases- „leaden paralysis”) Decreased concentration or indecisiveness, memory complaints  greatly impair work function (eldery patients- false diagnosis of dementia) Decrease or increase (atypical) in appetite OR significant weight loss or gain Psychomotor changes (retardation or agitation) Recurrent thoughts of death, suicidal ideations (2/3 poeple with depression) , or suicide attempt The most dangerous symptom are suicidal thoughts. They are ranging from fleeting thoughts of wishing everything would end to elaborate plans for suicide. The suicidal thoughts are present in nearly two-thirds of people with depression. Even when suicidal thoughts are serious, depressive patients often lack the energy and motivation to attempt suicide. However a suicide remains a significant issue as 10-15% hospitalized depressive patients eventually die by suicide. The period of high risk for suicide is during initial treatment, when energy and motivation may improve before improving low mood and hopelessness, what may possible for suicidal patient to act on their thoughts and plans.

Depressed mood or Anhedonia (loss of interest and pleasure) Persistently decreased (early, middle, late insomnia) or increased (atypical symptom) sleep if only sleep problems „masked depression” Feelings of worthlessness or inappropriate guilt (severe depression  delusions of guilt) Low energy or fatigue (↓ hygene, ↓ grooming) ( severe cases- „leaden paralysis”) Decreased concentration or indecisiveness, memory complaints  greatly impair work function (eldery patients- false diagnosis of dementia) Decrease or increase (atypical) in appetite OR significant weight loss or gain Psychomotor changes (retardation or agitation) Recurrent thoughts of death, suicidal ideations (2/3 people with depression) , or suicide attempt Other symptoms: anxiety, morning worsening of symptoms, chronic pain (if only chronic pain- „masked depression”) Anxiety with many subjective and physical manifestations is very common in depression. Increased irritability and mood swings, outburst of anger and sadness, frustration and irritation over minor matters also are frequently seen. Diurnal variation of mood, with morning worsening, may be present. Depression is also associated with increased frequency and magnification of physical pain, including headaches, backaches, and other chronic painful conditions. The symptoms have to last at least 2 weeks, when diagnosing clinical depression, or as it is called in clasification- major depressive episode. ≥ 5 symptoms present for ≥ 2 weeks

Diagnosis of depression: (AD) SIG E CAPS (medical mneumonic commonly used in the real world to diagnose depression) 1 or 2 major symptoms: Anhedonia and/or Depressed mood + ≥ 4 minor symptoms ≥ 2 weeks (SIG E CAPS) Sleep ↑ ↓ (changes in sleep pattern) Interest ↓ (loss of interest in activities) Guilt ↑ (feelings of worthlessness) Energy ↓ (fatique) Concentation/Cognition/Decisiveness ↓ (difficulty concentrating/decline in cognition/Indecisiveness Appetite ↑ ↓ (changes in appetite) Psychomotor ↑ ↓ (retardation or agitation) Suicide/Death ↑ (preoccupation) Originally, when physician would write a prescription, the abbreviation SIG would be written which was to mean directions to patient. The E caps was to remind the prescriber to write Energy Capsules for depression (antidepressants) hence SIG E C Mnemonic explanation can help you remember the vegetative signs that can be involved in depression.

Depression clip arts mnemonics (AD) SIG E CAPS
Anhedonia or Depressed mood and ≥ 4 of below for ≥ 2 weeks Anhedonia/Depressed mood

Anhedonia or Depressed mood and ≥ 4 of below for ≥ 2 weeks Anhedonia/Depressed mood Sleep- changes

Anhedonia or Depressed mood and ≥ 4 of below for ≥ 2 weeks Anhedonia/Depressed mood Sleep- changes Interest- loss

Anhedonia or Depressed mood and ≥ 4 of below for ≥ 2 weeks Anhedonia/Depressed mood Sleep- changes Interest- loss Guilt/worthlessness

Anhedonia or Depressed mood and ≥ 4 of below for ≥ 2 weeks Anhedonia/Depressed mood Sleep- changes Interest- loss Guilt/worthlessness Energy loss- fatique

Anhedonia or Depressed mood and ≥ 4 of below for ≥ 2 weeks Anhedonia/Depressed mood Sleep- changes Interest- loss Guilt/worthlessness Energy loss- fatique Concentration- difficulties /Indecisiveness

Anhedonia or Depressed mood and ≥ 4 of below for ≥ 2 weeks Anhedonia/Depressed mood Sleep- changes Interest- loss Guilt/worthlessness Energy loss- fatique Concentration- difficulties /Indecisiveness Appetite- changes

Anhedonia or Depressed mood and ≥ 4 of below for ≥ 2 weeks Anhedonia/Depressed mood Sleep- changes Interest- loss Guilt/worthlessness Energy loss- fatique Concentration- difficulties /Indecisiveness Appetite- changes Psychomotor-retardation or agitation

Anhedonia or Depressed mood and ≥ 4 of below for ≥ 2 weeks Anhedonia/Depressed mood Sleep- changes Interest- loss Guilt/worthlessness Energy loss- fatique Concentration- difficulties /Indecisiveness Appetite- changes Psychomotor-retardation or agitation Suicide/Death-preocupattion

Major Depressive Disorder specifiers
Mild/Moderate/Severe Severity Specifiers If Severe Without or With Psychotic Symptoms (typical are mood congruent delusions: guilt, sinfulness, bizzare illness) Psychosis Specifiers Partial Remission/Full Remission Remission Specifiers Information about severity of illness, psychotic symptoms and remission if any is present- is coded by numbers attached to the number of disorder

Major Depressive Episode specifiers
Melancholic Features Catatonic Features Postpartum Onset With Seasonal Pattern (SAD – Seasonal Affective Disorder) or winter depression Chronic full criteria of MDD >2 years Melancholic features: loss of pleasure in all activities, Morning worsening of symptoms Early morning awakening Marked psychomotor reardation or agitation, Significant weight loss or loss of appetite Excessive or inapripriate guilt Atypical features: hypersomnia and overeating, leaden paralysis Catatonic features

Major Depressive Disorder- diagnostic criteria
Presence of a Major Depressive Episode 1 Episode not better explained by another diagnosis, for example bereavement 2 NO HISTORY of mania, hypomania, or mixed episode (unless substance or medical illness related) 3

The Reccurent Course of Major Depressive Disorder
Depression Depression In the clasiffication there are as well specifiers connected with longitudinal course of the illness. This course can be with full interepisode recovery or without- with Dysthymic Disorder Friends Physical health School Job Marriage Out of job Finances

Major Depressive Disorder (outside psychiatric setting)
Up to 1/4 of patients with major medical comorbidity (cerebrovascular accidences, diabetes, cancer) will develop MDD, what has the huge effect on worsening their health. Less than half of primary care patients with mental illness receive ANY treatment. 50-70% MDD is NOT accurately diagnosed or treated in primary setting. Roughly 80% of all antidepressants are prescribed by non psychiatrists (Mark at all. 2009) (depression outside psychiatric setting) 1/Depression is very common, but the number of physical and cognitive symptoms associated with major depressive disorder means that many people don’t present with emotional symptoms and because of that they will not be diagnosed despite repeated health care visit. 2/ And it is not only psychiatrists and family physicians that need to diagnose depression. The high prevalence of MDD with other medical illnesses means that all physicians: internists, oncologists, neurologists, surgeons must also recognize and manage clinical depression in their patients. Depression had the biggest effect on worsening health especially when it is comorbid with chronic illnesses. In different countries, people with depression plus one or more chronic diseases were in the worst health Treatment of mental health conditions such as depression are a necessity, not a luxury.

Major Depressive Disorder- prognosis
For many patiens MDD can be a chronic relapsing illness Relapse within 6 months of recovery – 1/4 patients Risk of having another episode: ≥ 60% if one previous episode ≥ 90% if three previous episodes  severity of next episodes is greater 5%-10% will go on to develop Bipolar Disorder Chronically ill – 1/3 of patients The overall mortality risk ↑ 2 times (suicides, medical illnesses) The risk of death by suicide ↑ 26 times in untreated patients MDD- prognosis For many patients MDD can be a chronic relapsing illness. Relapse within first 6 month of recovery occurs in 1/4 patients. 60% will relapse within first 5 years. Moreover those patients that have had two previous depressive episodes have a 70% probability of third and having three previous depressive episodes have 90% likelihood of relapse. As disease progresses, the interval between depressive episodes becomes shorter and the severity of each episode becomes greater. About two-thirds of patients with a major depressive disorder fully recover from depressive episode, but one-third of depressed patients will either only partially recover or remain chronically ill. Those individuals who have residual depressive symptoms are at high risk of relapse, suicide, poor psychosocial functioning and higher mortality from other medical conditions. In addition to depression 5-10 % of individuals who have experienced major depressive disorder will subsequently have a manic or mixed episode indicative of bipolar disorder The risk of death by suicide increases 26 –fold in depressed patients. Depressed patients are at 2 times greater risk of developing a medical illness 1 year after diagnosis. Particularly there is a greater risk of cardiac infarction among patients with cardiovascular disease (direct effect- increased platelet aggregation, reduced heart rate variability, indirect effects- poor compliance with medications, drug and alcohol abuse, etc)

Major Depressive Disorder- Course
Approx. 50% people with first-episode depression experience a prodromal period (mild depressive symptoms and anxiety) Untreated mild/moderate episodes can last 1-6 months severe 6-8 months and even >12 months Treated depressive episode lasts on average 3 months About half of the people with first episode depression experience a prodromal period during which significant depressive symptoms are present . These symptoms, which could have been present for weeks to years prior to diagnosis, include anxiety and other mild depressive symptoms. Untreated depression can last 1-6 months for a mild to moderate depression, while severe episodes have an average length of 6-8 months. Nearly 25% of people with severe depressive episodes will have symptoms for more than 12 months Treated episodes last on average 3 months, however stopping antidepressants prior to 3 full months of use almost always results in the return of symptoms.

Major Depressive Disorder- epidemiology
Lifetime risk: 10%-25% for women 5%-12% for men Lifetime risk for developing depression is increasing (for people born after The II World War) Average age of onset in mid-20’s (trend of increasingly younger age of depression onset) 1/Depression is very common condition as the lifetime risk for experiencing major depressive disorder is approximately % for women and 5-12 % for men. The grater prevalence among women begins at the age of adolescence and it is common to find worsening the symptoms with the onset of menses. Despite hormonal differences, other hypothetical causes are psychosocial stressors and childbirth. Depression typically shows up in men, not as feelings of helplessness and vulnerability, but as being irritable, angry and uncooperative. Depression may therefore be difficult to recognise in such men. Even if a man realises that he is depressed, he is perhaps less willing than a woman to seek help. The gap between the sexes decreases after the age of as women enter menopause. 2/ Two major epidemiological trends are occurring with respect to depressive disorders . Firstly the lifetime risk of developing depression in those born after the Second World War is increasing. Secondly, there is a trend of increasingly younger age of depression onset. In worldwide population samples the average age for the onset of depression varies between 24 and 35 years with the mean age 27 years.

Etiology of Mood Disorders
Biological Factors Genetic Factors BP > UP Psychosocial Factors Biogenic amines (serotonin, norepinephrine, dopamine) HPA axis hypercortysolemia INFLAMMATION/NEUROTOXICITY ▪ Life events and environmental stress ▪ Personnality Factors Many studies have reported biological abnormalities in patients with mood disorders. Until recently disturbances in such neurotransmiters as serotonin, dopamine and norepinephrine were the main interest in the theory of this disorders. It was partly because of the antidepressive drugs mechanism of action which increases levels of these neurotransmiters. But now it is thought that neurotransmiters disturbances are secondary effect not directly connected with pathogenesis It is found as well that stress axis is elevated in depressed patients which is seen as hypercortisolemia (Hypothalamic -pituituary –adrenal) Numerous studies (family, adoption, twins ) have long documented the heritability of mood disorders, what is especially seen in families with bipolar disorders Psychosocial factors are connected with the observations that very often mood episodes especially when start first time are preceded by stresfull life events. For adults – the great risk factor is unemployment, the loss of a spouse Peronality factors include especially certain personality disorders- borderline, histrionic. But of course under certain circumstainces every person with any personality traits can become depressed.

SEROTONINERGIC ACTIVITY: PET STUDY
HEALTHY CONTROL PATIENT DURING DEPRESSION

Depressive disorders 1 1 Major Depressive Disorder (Unipolar Depression) 2 Dysthymic Disorder Single Episode Reccurent We’ve just discussed etiology od mood disorders, lets move to the next type

Milder but chronic depression.
Dysthymic Disorder Milder but chronic depression. Dysthymic disorder can be thought of as a paradoxical disorder. Though its symptoms are fairly mild on a day-to-day basis, over a lifetime DD is actually a severe disorder—leading to high rates of suicide, work impairment, and social isolation. In fact, the risk of suicide is higher with dysthymia than with major depression! People often don’t seek treatment because of the dysthymia, because they think they are simply like that: they have low selfesteem, low energy level, often complain, that have simply this kind of charakter. They visited psychiatrists only when they got another psychiatric problems: major depression (we then describe their symptoms as double depression), anxiety. Research studies have shown that there are more subtle symptoms of DD as well, which may be even more common. People with DD are also often socially withdrawn, and perform below their abilities at work and school. They often find it difficult to take normal day-to-day risks such as asking someone out on a date, or calling to apply for a job. They are often easily discouraged. They are often overly pessimistic. Could you imagine a person with dysthymic disorder? Sometimes I show my students well known movie characters presenting with mental problems. And for now: Depressed mood nearly every day for > 2 years Associated with ≥ 2 of the following: decreased or increased appetite decreased or increased sleep low energy or fatigue low self-esteem poor concentration or indecisiveness hopelessness

Who was dysthymic in „Winnie the Pooh”?

Eeyore It is Eeyore, of course. Eeyore with low self esteem, overly pessimistic and complaining.

Depressive Disorders Major Depressive Disorder Dysthymic Disorder Single Episode Reccurent There are two types of adjustment disorder: with depressed mood and with mixed anxiety and depression. Adjustment Mood Disorder

Adjustment Disorder with Depressed Mood
In short, it is a stress related disturbance. A stressor is anything that causes a great deal of stress in the person's life. It could be a positive event, like a wedding or purchasing a new home, or a negative event, like a family member's death, the breakup of an important relationship, or loss of a job. In our everyday practice we treat people who get unemploed, it is common situation. Sometimes there are people who are mistreated in their work. stress related disturbance

Adjustment Disorder with Depressed Mood
Depressive symptoms that develop within 3 months of a stressor (negative and positive events) Symptoms do not meet criteria for another mood episode Symptoms are clinically significant because of: Marked distress is in excess of what would be expected OR Significant social or occupational impairment These symptoms or behaviors are clinically significant as evidenced by either of the following: Marked distress that is in excess of what would be expected from exposure to the stressor Significant impairment in social, occupational or educational functioning The stress-related disturbance does not meet the criteria for another specific mental disorder. Once the stressor (or its consequences) has ended, the symptoms do not persist for more than an additional 6 months. By definition, if patient’s depressive feelings related to the event last longer than 6 months, it will no longer qualify for an adjustment disorder diagnosis. An adjustment disorder can occur at any time during a person's life and there is no difference in the frequency of this disorder between males and females. An adjustment disorder is diagnosed by a mental health professional through a simple clinical interview.

Bereavement (mourning, grief)
“Normal” reaction to the loss of a loved one May have several depressive symptoms Consider diagnosis of major depressive episode if: Symptoms persist > 2 months after loss Presence of any of the following: Guilt (except for actions taken or not taken at time of death) Profound and persistent anhedonia Marked psychomotor retardation Decreased self-esteem Suicidal ideation Hallucinations other than hearing voice or seeing image of deceased person (DSM-IV) considers the depression associated with bereavement a "normal" reaction to loss, provided it is does not linger too long. Depression which lingers beyond what is expected, could be a sign that the stress of grieving has triggered a Major Depressive Episode. Studies have shown that the extreme stress associated with grief can trigger both medical illnesses, such as heart disease, cancer and the common cold, as well as psychiatric disorders like depression and anxiety There is no way to define a "normal" length of bereavement since it varies from person to person and culture to culture. According to the DSM-IV, a diagnosis of Major Depressive Disorder is generally not given unless symptoms have lasted beyond two months. How to Distinguish Grief From Major Depression? Grief has several symptoms in common with Major Depressive Disorder including sadness, insomnia, poor appetite and weight loss. Major depression, tends to be more pervasive, with the person rarely getting any relief from their symptoms. Grieving person may feel relatively better while in certain situations, such as when friends and family are around to support them.

A well-known man who suffered from depression…
In the middle is a drawing made by polish famous ilustrator of fairy tails: The little match girl

Famous people suffering from depression
Gwyneth Paltrow J.K.Rowling - In fact, her emotional struggles with depression provided inspiration for some of her characters J.K.Rowling Hugh Laurie

BIPOLAR DISORDERS The documented history of bipolar disorder dates back as far as the time of ancient Greece, nearly 2000 years ago.

Jules Francois Baillarger 1853
The illness was separated from schizophrenia Extreme mood changes are different phases of the same illness Aretaeus of Cappadocia 150 AD, mania and melancholy are the same illness It was Aretaeus of Cappadocia (a city in ancient Turkey), a celebrated Greek physician, who first put forward that these extremes of mood were a part of the same illness, but it has been not until much later that this view gained importance. Bipolar Disorder has been molded by differing theories over time until it actually had its own classification. For many years Bipolar Disorder was linked to Schizophrenia. Only Jules Francois Baillarger a French neurologist, in the mid of ninetheen century believed there was a major distinction between bipolar disorder and schizophrenia and through his studies was finally successful in separating the two disorders and described these extreme mood changes as being different phases of the same illness translated from French as ‘dual-form insanity’. And finally the German psychiatrist Emil Kraepelin in 1899 first used the term manic depressive illness to describe these phases. However, it wasn’t until much later that another German, Karl Kleist, in 1953 separated out unipolar depression where there are no periods of mania or hypomania, and the term bipolar disorder was born. Emil Kraepelin 1899 Name: manic-depressive illness Karl Kleist 1953 separated out unipolar depression, The term: Bipolar Disorder

Bipolar Disorders Bipolar I Disorder Bipolar II Disorder Bipolar NOS (Not Other Specified) Now, we have official classification of bipolar disorders. You can see that the group is subdivided into Bipolar type I, bipolar type II, cyclothymic disorder and bipolar Nos. It may be surprising that the term bipolar disorder is still evolving, for example we often use the term bipolar spectrum, which is not found in clasification. Bipolar spectrum includes people with depression who have only one or a few traces of bipolarity. Sometimes it is very important to detect those very small bipolarity traces to chose optimal treatment for the patient. Cyclothymic Disorder

Bipolar I and Bipolar II
Manic state is in some way opposite to depression, The criteria for major depressive episode in bipolar disorder are essentially the same as those of unipolar depression Typically, the features of bipolar depression are more melancholic than those of unipolar depression with the greater likelihood of psychomotor retardation and atypical symptoms like hypersomnia and increased appetite especially sweets craving.

Manic Episode Elevated (or irritable) mood for >1 week (or less if must be hospitalized) Mania, what is manic episode, defines bipolar disorder and typically, it is easily identifided change in mental state during which the individual is euphoric, expansive or irritable in terms of mood. First criterion is elevated mood At the beggining of the phase the patient gives the impression that he was joking, he's funny. But it lasts only until someone wants to stop him or doesnt agree with him, he easily get irritable or very often angry.

Manic Episode Elevated (or irritable) mood for >1 week (or less if must be hospitalized) ≥ 3 of following (4 if mood irritable): Decreased need for sleep In addition, the person usually describes a decreased need for sleep

Manic Episode Elevated (or irritable) mood for >1 week week (or less if must be hospitalized) ≥ 3 of following (4 if mood irritable): Decreased need for sleep Increased goal-directed activity This is along with marked increase in energy (either socially, at work, at school) or sexually or psychomotor agitation

Manic Episode Elevated (or irritable) mood for >1 week week (or less if must be hospitalized) ≥ 3 of following (4 if mood irritable): Decreased need for sleep Increased goal-directed activity Distractibility Often attention is limited and person is distractible. The patient is unable to focus on one topic more than for a short time

Manic Episode Elevated (or irritable) mood for >1 week week (or less if must be hospitalized) ≥ 3 of following (4 if mood irritable): Decreased need for sleep Increased goal-directed activity Distractibility Flight of ideas, racing thoughts Farther, indywiduals describe their thoughts as racing

Manic Episode Elevated (or irritable) mood for >1 week week (or less if must be hospitalized) ≥ 3 of following (4 if mood irritable): Decreased need for sleep Increased goal-directed activity Distractibility Flight of ideas, racing thoughts Excessive involvement in pleasurable activities with high risk Their judgment is often impaired during a manic episode and can result in dangerous and indiscreet behaviour ranging from overspending money, being sexually inappriopiate to unnecessary risk taking and self harm. Patients very often excessive drink alkohol or use substance and can become aggresssive and cant control their behaviour

Manic Episode Elevated (or irritable) mood for >1 week week (or less if must be hospitalized) ≥ 3 of following (4 if mood irritable): Decreased need for sleep Increased goal-directed activity Distractibility Flight of ideas, racing thoughts Excessive involvement in pleasurable activities with high risk Pressured speech They are talking much faster than usual, and it is often difficult for health care professionals to interrupt the patient.

Manic Episode Elevated (or irritable) mood for >1 week week (or less if must be hospitalized) ≥ 3 of following (4 if mood irritable): Decreased need for sleep Increased goal-directed activity Distractibility Flight of ideas, racing thoughts Excessive involvement in pleasurable activities with high risk Pressured speech Grandiosity It is not unusual that they have inflated selfesteem and feel that they are special or have grandiose and delusional ideas. Indeed, when mania is severe, it often melds into psychosis

Diagnosis of mania: (DIG FAST) (medical mneumonic commonly used in the real world to remember symptoms of mania) Distractibility (and easy frustration) Irresponsibility (and erratic uninhibited behaviour) Grandiosity Flight of ideas (and racing thoughts) Activity increased (with weight loss and increased libido) Sleep decreased Talkativeness To remember the abbreviation DIG FAST You could imagine the manic patient outside in the garden digging fiercely with the shovel.

Mania (clip arts mnemonics) DIG FAST
or Elevated expansive mood Irritable mood

or Elevated expansive mood Irritable mood Distractibility

or Elevated expansive mood Irritable mood Irresponsibility and erratic uninhibited behaviour Distractibility

or Elevated expansive mood Irritable mood Irresponsibility and erratic uninhibited behaviour Distractibility Grandiosity

or Elevated expansive mood Irritable mood Irresponsibility and erratic uninhibited behaviour Distractibility Grandiosity Flight of ideas/Racing thoughts

or Elevated expansive mood Irritable mood Irresponsibility and erratic uninhibited behaviour Distractibility Grandiosity Activity increased/ Psychomotor agitation Flight of ideas/Racing thoughts

or Elevated expansive mood Irritable mood Irresponsibility and erratic uninhibited behaviour Distractibility Grandiosity Sleep decreased Activity increased/ Psychomotor agitation Flight of ideas/Racing thoughts

or Elevated expansive mood Irritable mood Irresponsibility and erratic uninhibited behaviour Distractibility Grandiosity Sleep decreased Talkativeness Activity increased/ Psychomotor agitation Flight of ideas/Racing thoughts

The Course of Bipolar I Depression Mixed state School Friends Job
Mania Mania Mixed state: Patient meets criteria for a major depressive episode AND a manic episode at the same time Symptoms persist for at least 1 week Depression Depression Mixed state School Friends Job Marriage Finances Physical health

Bipolar Disorder specifiers
Mild/Moderate/Severe Severity Specifiers If Severe Without or With Psychotic Symptoms  only type I (typical are mood congruent delusions: Grandiose Psychosis Specifiers Partial Remission/Full Remission Remission Specifiers

Bipolar Disorder specifiers
Melancholic Features Catatonic Features Postpartum Onset Rapid Cycling With Seasonal Pattern (SAD – Seasonal Affective Disorder)

The Course of Bipolar -Rapid cycling
This course is considered to be more difficult to treat Qualifier for Bipolar I and Bipolar II Disorder ≥ 4 mood episodes (any type) within any 1 year period difficult to treat

Rapid cycling It is interesting that rapid cycling course could be more intense, what doesn't fit the official model because bipolar disorder is supposed to have phases lasting at least 4 days. But the shorter versions are seen so often they have their own names, as shown below. Especially when the young perosn has this type of very frequent phases, sometimes even mixed, it is extremely difficult to recognise the disorder. Young people are considered as moody, having adolescense problems, behavioural personal disturbances Sometimes it lasts many years to finally establish the diagnosis, many wasted years without adequate treatment

Bipolar I- diagnosis At least one manic or mixed episode
No need for a prior depressive episode Symptoms cause significant impairment in social and/or occupational functioning Symptoms do not result from a drug of abuse, medication, other treatment, or general medical condition Could be delusions  what need additional treatment

Bipolar I- frequency of symptoms
We can see that manic/hypomanic together with mixed episodes are roughly one third of all symptoms Patient’s manic behaviour draws such an attention, that there is no need to be a psychiatrist to recognise that something is wrong Paul E. Keck, Jr, MD, Roger S. McIntyre, MD, FRCPC, and Richard C. Shelton, Bipolar Depression: Best Practices for the Outpatient MDCNS Spectr. 2007;12:12(Suppl 20):1-16

Bipolar II Disorder

Hypomanic Episode Elevated, expansive, or irritable mood lasting > 4 days – clearly different from baseline Three or more of the following (four if mood irritable): Little need for sleep Increased goal-directed activity Flight of ideas, racing thoughts Distractibility Excessive involvement in pleasurable activities with high risk Rapid speech Overconfidence Clear change in functioning but no marked impairment in social or occupational functioning Technically, this is literally a "little" mania — the familiar symptoms but less so: Mood much better than normal Little need for sleep Continuous high energy trouble concentrating Racing thoughts, Rapid speech Overconfidence The people are often consider higly functional and their ideas are welcomed You may have noticed that "delusions" have disappeared from the list: these are by definition not found in Bipolar II.

Bipolar II Disorder- diagnosis
At least one previous major depressive episode At least one hypomanic episode Less severe than Bipolar I and more difficult to diagnose It is more severe than bipolar I, because of high rate of suicidality SSRI sexual disinhibition- soft bipolar trate

Bipolar II- frequency of symptoms
Bipolar II is believed to be under-diagnosed because hypomanic behavior often presents as high-functioning behavior.[2] Those with bipolar II are at highest risk of suicide among the bipolar spectrum. Patients with depression in Bipolar II, very often dont remember that they were felt better somewhere in the past. Paul E. Keck, Jr, MD, Roger S. McIntyre, MD, FRCPC, and Richard C. Shelton, Bipolar Depression: Best Practices for the Outpatient MDCNS Spectr. 2007;12:12(Suppl 20):1-16

Bipolar Disorders- Epidemiology
Lifetime risk: Bipolar I Disorder: 1% (men = women) Bipolar II Disorder: 0,4% (adults) * 3-4% (adolescens) * Age of onset late teens to early 20’s * Merikangas KR, Lamers F. Curr Opin Psychiatry Jan;25(1):19-23 The 'true' prevalence of bipolar II disorder PURPOSE OF REVIEW: Many studies - including meta-analyses - do not distinguish between bipolar I and II disorder. The aim of this study is to review the recent literature on the prevalence, correlates, consequences, and treatment patterns of bipolar II disorder. RECENT FINDINGS: In the past 2 years, several important studies have been conducted in the bipolar II field. The World Mental Health Survey initiative provides us with prevalence rate across 11 countries, while several meta-analyses on suicide and neurocognition directly compared bipolar I with bipolar II, informing us on the severe consequences of bipolar II disorder. Results from studies showed that the lifetime prevalence rate of bipolar II disorder in adults across 11 countries was 0.4%. Rates of bipolar II disorder in prospective studies of adolescents are substantially greater, with lifetime rates approaching 3-4%. SUMMARY: Evidence from these studies regarding comparable clinical consequences, patterns of comorbidity, suicide attempts, family history, and treatment patterns to bipolar I disorder document the validity of the bipolar II subtype.

Famous bipolar people Curt Cobain Robert Downey jr. Mel Gibson
many famous people are believed to have been affected by bipolar disorder. Most of these listed have been diagnosed based on evidence in their own writings and contemporaneous accounts by those who knew them. It is often suggested that genius (or, at least, creative talent) and mental disorder (specifically, the mania and hypomania of bipolar disorder) is linked; the connection was widely publicized by Kay Redfield Jamison in Touched with Fire, although many of the diagnoses in the book are made by Jamison herself. Also, persons prior to the 20th century may have incomplete or speculative diagnoses of bipolar disorder Kurt Cobain was the guitarist/vocalists/song writer of Nirvana., Mel Gibson –American actor, in the photo in the film the Bravewheart Rober Downey jr Robert Downey jr. Mel Gibson

Bipolar Disorders Bipolar I Bipolar NOS Bipolar II Cyclothymic Disorder

Cyclothymic Disorder ≥ 2 years
Hypomanic episodes and depressive symptoms alternate over at least 2 years Several distinct periods of hypomanic and depressive symptoms (not MDD) Symptom-free periods are < 2 months

Mood Disorders (affective disorders)

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Mood Disorders (affective disorders)

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