Bipolar Disorders

Bipolar Disorders

Psychiatry 2

Dr. Besa

First Shifting

24 July 2008

BIPOLAR DISORDER – both manic and depressive episodes or manic episodes alone HYPOMANIA – manic symptoms that does not meet DSM-IV-TR CYCLOTHYMIA – less severe form of bipolar disorder DYSTHYMIA – less severe form of major depression

History • • • •

Hippocrates – mania and melancholia Jules Falret – folie circulaire: alternating moods of depression and mania Karl Kahlbaum – cyclothymia Emil Kraeplin – bipolar I disorder and involutional melancholia

Epidemiology • •

• • • •

Lifetime prevalence: 2.4% Bipolar I –equal men & women Manic episodes ◦ More common in men ◦ Women have higher rate for rapid cyclers Age: 5-6 years old, to 50 mean age=30 Marital status: divorce and single Socioeconomic: upper socioeconomic groups

Comorbidity •

•

Substance abuse (self medication with alcohol) Anxiety disorder: worsen prognosis and increase risk of suicide

•

Glutamate & Glycine – neurotoxic effects; glutamate + hypercortisolemia = depression

Hormones • TSH - depression • GH – inh by somatostatin and CRH; ↓somatostatin in depression, ↑ in mania • Prolactin – stim by serotonin, inh by dopamine Sleep: depression ↓lymphocytes: depression Brain (in Mania): Increased frequency of abnormal hyperintensities in subcortical region

GENETIC FACTORS • Family: Depression • Adoption: 3x increase in bipolar • Twins: 50-70%; monozygotic 70-90%, dizygotic

16-35% Linkage: chr 18q and 22q; 18 fr mother, 21q in schiz & bipolar, 22q (BCR gene) in neuron growth & axonal guidance

•

PSYCHOSOCIAL • Life events & envtl stess: depression • Personality factors: OCD, histrionic

& borderline in depression; dysthymic and cyclothymic d/o in MDD or bipolar I d/o Psychodynamic Factors ◦ defense against underlying depression ◦ Abraham: inability to tolerate development tragedy; result from tyrannical superego → intolerable self-critism → euphoric selfsatisfaction ◦ Lewin: ego overwhelmed by pleasurable impulses ◦ Klein: defensive reaction to depression

•

Etiology BIOLOGICAL FACTORS -

Monoaminergic systems

Biogenic amines • NE & serotonin - depression • Dopamine - reduced in depression, increased in mania - Reduce dopamine: reserpine, Parkinson’s dse - Increased dopamine: tyrosine, amphetamine, buproprion (Wellbutrin) Other NTs • ACh – agonists produce lethargy, anergia, psychomotor retardation, exacerbate sx of depression, reduce sx of mania • GABA – reduction in depression Chicha’s grp = junk food’s grp

Diagnosis BIPOLAR I DISORDER -

-

Bipolar II: depressive and hypomanic Manic ppt by antidepressant tx ≠ bipolar I Criteria for Manic: • Persistently elevated, expansive and irritable mood, one week • 3 or more of the following symptoms: ◦ Grandiosity ◦ Decrease need for sleep ◦ More talkative 1 of 8

PSYCH2 BIPOLAR DISORDERS

◦ ◦ ◦

• • •

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

Chicha’s grp = junk food’s grp

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PSYCH2 BIPOLAR DISORDERS

Bipolar I disorder, single manic episode - Manic Episode – 1st manic episode Table 15.1-14 A. Presence of only one manic episode and no past major depressive episodes. Note: Recurrence is defined as either a change in polarity from depression or an interval of at least 2 months w/o manic symptoms. B.

The manic episode is not better accounted for by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.

Specify if : Mixed: If symptoms meet criteria for a mixed episode if the full criteria are currently met for a manic, mixed, or major depressive episode, specify its current clinical status and/or features: Mild, moderate, severe w/o psychotic features/severe with psychotic features With catatonic features, with postpartum onset If the full criteria are not currently met for a manic, mixed or major depressive episode, specify the current clinical status of bipolar I disorder or features of the most recent episode: In partial remission, in full remission With catatonic features With postpartum onset

With rapid cycling.

•

Bipolar I disorder, most hypomanic (Table 15.1-16)

A.

Currently (or most recently) in a hypomanic episode. There has previously been at least one manic episode or mixed episode. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The mood episode in criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.

B. C. D.

• A. B. C.

A. B. C.

Bipolar I disorder, most recent episode manic (Table 15.1-15) Currently ( or most recently) in manic episode. There has previously been at least one major depressive episode, manic episode, or mixed episode. The mood episode in criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.

If the full criteria are currently met for a manic episode, specify its current clinical status and/or features: Mild, moderate, severe w/o psychotic features/severe with psychotic features With catatonic features, with postpartum onset If the full criteria are not currently met for a manic episode, specify the current clinical status of bipolar I disorder and/or features of the most recent manic episode: In partial remission, in full remission With catatonic features With postpartum onset Specify if: Longitudinal course specifies (with and w/o interepisode recovery) With seasonal pattern (applies only to the pattern of major depressive episodes) Chicha’s grp = junk food’s grp

episode

Specify if: Longitudinal course specifies (with and w/o interepisode recovery) With seasonal pattern (applies only to the pattern of major depressive episodes) With rapid cycling.

Bipolar I disorder, recurrent separated by at least 2 months without significant symptoms of mania or hypomania

•

recent

Bipolar I disorder, most recent episode depressed (Table 15.1-17) Currently (or most recently) in a major depressive episode. There has previously been at least one manic episode or mixed episode. The mood episode in criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.

If the full criteria are currently met for major depressive episode, specify its current clinical status and /or features: Mild, moderate, sever w/o psychotic features, sever w/ psychotic features, Chronic With catatonic features With melancholic features With atypical features With postpartum onset If the full criteria are not currently met for a major depressive episode, specify the current clinical status of bipolar I disorder and/or features of the most recent major depressive episode: In partial remission, in full remission Chronic With catatonic features With melancholic features With atypical features With postpartum onset Specify if: Longitudinal course specifies (with and w/o interepisode recovery) With seasonal pattern (applies only to the pattern of major depressive episodes) With rapid cycling

•

Bipolar I disorder, most recent episode mixed (Table 15.1-18)

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PSYCH2 BIPOLAR DISORDERS A. B. C.

Currently (or most recently) in a major depressive episode. There has previously been at least one major depressive episode, manic episodes or mixed episode. The mood episode in criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.

If the full criteria are currently met for mixed episode, specify its current clinical status and /or features: Mild, moderate, sever w/o psychotic features, sever w/ psychotic features, With catatonic features With postpartum onset If the full criteria are not currently met for a mixed episode, specify the current clinical status of bipolar I disorder and/or features of the most recent mixed episode: In partial remission, in full remission With catatonic features With postpartum onset Specify if: Longitudinal course specifies (with and w/o interepisode recovery) With seasonal pattern (applies only to the pattern of major depressive episodes) With rapid cycling.

• A. B. C. D.

E.

Bipolar I disorder, most recent episode unspecified (Table 15.1-19) Criteria, except for duration, are currently ( or most recently) met for a manic, a hypomanic, a mixed, or major depressive episode. There has previously been at least one manic episode or mixed episode. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The mood symptoms in criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified. The mood symptoms in criteria A and B are not due to the direct physiological effects of a substance( e.g. a drug of abuse, medication, or other treatment) or general medical condition( e.g. hyperthyroidism).

Specify if: Longitudinal course specifies (with and w/o interepisode recovery) With seasonal pattern (applies only to the pattern of major depressive episodes) With rapid cycling.

Criteria for Severity/Psychotic/Remission Specifiers for Current (or Most Recent MANIC episode (Table 15.1-10) Note: Code in fifth digit. Mild, moderate, severe w/o psychotic features, severe w/psychotic features can be applied only if the criteria are currently met for manic episode. In partial remission and in full remission can be applied to a manic episode in bipolar I disorder only if it is the most recent type of mood episode. Chicha’s grp = junk food’s grp

Mild: Minimum symptom criteria are met for a manic episode. Moderate: Extreme increase in activity or impairment in judgment. Severe without psychotic features: Almost continual supervision required to prevent physical harm to self and other. Severe with psychotic features: Delusion or hallucination. If possible, specify whether the psychotic features are mood- congruent: Mood- congruent psychotic features: delusion or hallucination whose content is entirely consistent with the typical manic themes or inflated worth, power, knowledge, identity, or special relationship to deity or famous person. Mood- incongruent psychotic features: Delusion or hallucination whose content does not consistent with the typical manic themes or inflated worth, power, knowledge, identity, or special relationship to deity or famous person. Included are such symptoms as persecutory delusion (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled. In partial remission: Symptoms of manic episode are present but full are not met, or there is a period w/o any significant symptoms of manic episode lasting 2 months following the end of manic episode. In full remission: During the past 2 months no significant signs or symptoms of disturbance were present.

Hypomanic - Persistently elevated, expansive and irritable mood, lasting at least 4 days 3 or more of same symptoms Uncharacteristic of the person Change in functioning observable by others NOT SEVERE to cause marked impairment or to necessitate hospitalization Not due to substance abuse, GMC Mixed Episode Met for both manic and depress episodes everyday for 1 week Severe to cause impairment Not due to substance, GMC Criteria for Severity/Psychotic/Remission Specifiers for Current (or Most Recent MIXED episode Table 15.1-11 Note: Code in fifth digit. Mild, moderate, severe w/o psychotic features, severe w/psychotic features can be applied only if the criteria are currently met for mixed episode. In partial remission and in full remission can be applied to a mixed episode in bipolar I disorder only if it is the most recent type of mood episode. Mild: No more than minimum symptom criteria are met for a manic episode and major depressive episode. Moderate: Symptoms or functional impairment between mild and severe. Severe without psychotic features: Almost continual supervision required to prevent physical harm to self and other. Severe with psychotic features: Delusion or hallucination. If possible, specify whether the psychotic features are mood- congruent or mood- incongruent:

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PSYCH2 BIPOLAR DISORDERS Mood- congruent psychotic features: delusion or hallucination whose content is entirely consistent with the typical manic themes or depressive themes. Mood- incongruent psychotic features: Delusion or hallucination whose content does not involved with the typical manic theme or depressive theme. Included are such symptoms as persecutory delusion (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled. In partial remission: Symptoms of mixed episode are present but full are not met, or there is a period w/o any significant symptoms of mixed episode lasting 2 months following the end of mixed episode. In full remission: During the past 2 months no significant signs or symptoms of disturbance were present.

BIPOLAR II DISORDER -

A. B. C. D.

E.

One or more depressive episode At least one hypomanic episode Never had manic or mixed episode Not due to schizophrenia Significant impairment

Presence (or history) of one or more major depressive episode. Presence (or history) of the least one hypomanic episode. There has been a manic episode or mixed episode. The mood symptoms in criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify current or most recent episode: Hypomanic: if currently ( or most recently ) in a hypomanic episode. Depressed: if currently ( or most recently ) in a major depressive episode. If the full criteria are currently met for major depressive episode, specify its current clinical status or features: Mild, moderate, severe w/o psychotic features severe w/psychotic features. Note: Fifth-digit codes cannot be used here because the code for bipolar II disorder already uses the fifth digit. Chronic With catatonics features With melancholic features With atypical features With postpartum onset If the full criteria are not currently met for a hypomanic or major depressive episode, specify its current clinical status or features of the bipolar II disorder and/or features of the most recent major depressive episode ( only if it is the most recent type of mood episode): In partial remission, In full remission: Note : Fifthdigit codes cannot be used here because the code for bipolar II disorder already uses the fifth digit. Chronic With catatonics features With melancholic features With atypical features With postpartum onset Specify if: Chicha’s grp = junk food’s grp

Longitudinal course specifies (with and w/o interepisode recovery) With seasonal pattern (applies only to the pattern of major depressive episodes) With rapid cycling.

Recurrent Course: • With rapid cycling: BID, BIID • With seasonal pattern: BID, BIID, MDD • With or without full interepisode recovery: BID, BIID, MDD • With postpartum onset: BID, BIID, MDD, BPD (brief psychotic disorder) • Rapid cycling: BID, BIID ◦ Female with depressive and hypomanic episodes ◦ Stress or drug treatment ◦ 4 episodes in 1 year

SPECIFIERS (MOST

RECENT EPISODE )

With Psychotic Features Poor prognostic indicator Bipolar I: families of probands with psychotic depression Mood congruent: “I deserve to be punished bec I am so bad” Mood incongruent: may have schizoaffective disorder or schizophrenia Poor prognosis: long duration of episodes, temporal dissociation, poor premorbid history Tx: antipsychotic drugs + antidepressants or mood stabilizers With Melancholic Features - Severe anhedonia, early morning awakening, weight loss, and profound feelings of guilt Assoc with changes in ANS and endocrine fcns “endogenous depression”: depression in the absence of external life stressors Specify if: With melancholic features: (can be applied to the current or most recent major depressive episode in major depressive disorder and to a major depressive episode in bipolar I or bipolar II disorder only if it is the most recent type of mood episode). A. Either of the following, occurring during the most severe period of the current episode: (1) Loss of pleasure in all, or almost all, activities. (2) Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens).

B.

Three (or more) of the following: (1) Distinct quality of depressed mood (i.e., the depressed mood is experienced after the death of loved one) (2) Depression regularly worse in the morning (3) Early morning awakening (at least 2 hours before usual time of awakening) (4) Marked psychomotor retardation or agitation (5) Significant anorexia or weight loss (6) Excessive or inappropriate guilt

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PSYCH2 BIPOLAR DISORDERS

Postpartum Onset With Atypical Features Reversed vegetative symptoms; sx pattern: hysteroid dysphoria Younger onset of age More severe psychomotor slowing More frequent coexisting diagnoses of panic disorder, substance abuse or dependence, and somatisation disorder Long term cause Specify if: With Atypical Features (can be applied when these features predominate during the most recent 2 weeks of a current major depressive episode in major depressive disorder or in bipolar I or bipolar II disorder when a current major depressive episode is the most recent type of mood episode,or when these features predominated during the most recent 2 years of dysthymic disorder: if the major depressive episode is not current, it applies if the features predominates during 2 weeks period) A. Mood activity ( i.e., mood brightens in response to actual or potential positive events) B. Two (or more) of the following features: (1) Significant weight gain or increase in appetite (2) Hypersomnia (3) Leaden paralysis ( i.e., heavy, leaden, feelings arms or legs ) (4) Long- standing pattern of interpersonal rejection sensitivity ( not limited to episodes mood disturbance) that results in significant social or occupational impairment. C. Criteria are not met for with melancholic features or with catatonic features during the same episode.

With Catatonic Features Most commonly schizophrenia disorder Prognostic and tx significance

and

mood

Specify if: With Catatonic Features (can be applied to the current or most recent major depressive episode, manic episode, or mixed episode in major depressive disorder, bipolar I or bipolar II disorder). The clinical picture is dominated by at least 2 of the following: (1) Motoric immobility as evidence by catalepsy (including waxy flexibility) or stupor. (2) Excessive motor activity (that is apparently purposeless and not influenced by external stimuli) (3) Extreme negativism (an apparently motiveless resistance to all instruction or maintenance of a rigid posture against attempts to be moved) or mutism (4) Peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre posture), stereotyped movements, prominent mannerism, or prominent primacing (5) Echolalia or echopraxia

Chicha’s grp = junk food’s grp

Specify if: Postpartum Onset (can be applied to the current or most recent major depressive, manic, or mixed episode in major depressive disorder, bipolar I disorder, bipolar II disorder; or to brief psychotic disorder) Onset of episode within 4 weeks postpartum.

Chronic Specify if: Chronic (can be applied to the current or most recent major depressive episode in major depressive disorder and to a major depressive episode in bipolar I or II disorder only if it is the most recent type of mood episode) Full criteria for major depressive episode have been met continuously for at least the past 2 years.

DESCRIBING COURSE

FOR

RECURRENT EPISODES

Rapid Cycling Female Depresseive and hypomanic episodes Pathogenesis: stress or drug treatment At least 4 episodes within 12 month period Specify if: Rapid Cycling (can be applied to bipolar I disorder or bipolar II disorder) At least four episode of a mood disturbance in the previous 12 months that meet the criteria for major depressive, manic, mixed, or hypomanic episode. Note: Episode are demarcated either by partial or full remission for at least 2 months or switch to an episode of opposite polarity (e.g., major depressive episode to manic episode).

Seasonal Pattern Most commonly winter Seasonal affective disorder 2 evidence 1. Likely to respond to light therapy 2. Decreased metabolic activity in the orbital frontal cortex and left inferior parietal lobe Specify if: Seasonal Pattern (can be applied to the pattern of major depressive episode in bipolar I disorder, bipolar II disorder, or major depressive disorder, recurrent). A. There has been a regular temporal relationship between the onset of major depressive episode in bipolar I or II disorder or major depressive disorder, recurrent and a particular time of the year (e.g., regular appearance of the major episode in the fall or winter). NOTE: do not include cases in which there is an obvious effect of seasonal-related psychosocial stressor (e.g, regularly being unemployed every winter). B. Full remission (or a change from depression to mania or hypomania) also occur at a characteristic time of the year (e.g., depression disappears in the spring).

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PSYCH2 BIPOLAR DISORDERS C.

D.

In the last 2 years, two major depressive episode have occurred that demonstrate the temporal seasonal relationship defined in criteria A and B, and no non seasonal major depressive episode have occurred during the same period Seasonal major depressive major depressive episodes (as describe above) substantially outnumber the nonseasonal major depressive episodes that may have occurred over individual’s lifetime.

Longitudinal Course Specifiers Specify if (can be applied to recurrent major depressive disorder or bipolar I or II disorder): With full interepisode recovery: in full remission is attained between two most recent mood episodes Without full interepisode recovery: if full remission is not attained between the two most recent mood episode.

NON-DSM-IV-TR TYPES •

• • •

•

Endogenous-reactive continuum Endogenous depressions are biological; Reactive depressions are psychological Endogenous depression: similar to MDD w/ psychotic features or melancholic features Reactive depression: initial insomnia, anxiety, emotional lability, multiple somatic complaints Primary Depression: Mood disorders caused by GMC Secondary Depression: substance-induced mood disorder Double Depression: MDD superimposed on dysthymic d/o Depressive equivalent: forme fruste of depressive episode

•

Other Substance-Related Disorders: ppt an episode of illness or patient’s attempt to treat their own illnesses; cocaine & amphetamine Medical Conditions: older persons; medical condition/drugs taking = depression; cancer

•

MSE

Speech: Perceptual disturbance: Thought: Sensorium and memory: Impulse control: Judgement and insight: Reliability:

Course and Prognosis BID • • •

• •

• •

Clinical Features MANIC EPISODES • Hallmark: Elevated/euphoric, • • • • •

expansive,

irritable mood Excessive alcohol intake to self-medicate Disinhibited nature Act impulsively with sense of conviction and purpose Preoccupied with religious, political, financial, sexual, persecutory ideas In adolescents: often misdiagnosed as antisocial personality disorder or schizophrenia

BIID • •

MDD + hypomanic More marital disruption Onset at an earlier age

C OEXISTING DISORDERS • Anxiety: mixed anxiety-depressive disorder • Alcohol Dependence: women

Diagnosis is stable Chronic disease that treatment strategies

needs

loner

term

ACUTE MANIC •

•

Mood stabilizers: ◦ Lithium = best; 900-1800 mg/day ◦ Valproate = 750-2000 mg/day ◦ Carbamazepine = 800-1800 mg/day ◦ Clonazepam Atypical and typical antipsychotic (alone) ◦ Risperdal ◦ Abilify

ACUTE BIPOLAR DEPRESSION • • •

Chicha’s grp = junk food’s grp

Graphing the course patient’s disorder Starts with depression (usually) Recurring disorder Manic episodes have rapid onset, untreated episodes lasts 3 months Time between episodes decreases 4 or more episodes a year  rapid cycler Poor prognosis: poor occupational status, alcohol dependence, psychotic features, male gender

Treatment

BIPOLAR II DISORDER • • •

Euphoric, very loud voice Elevated mood Loud voice, flight of ideas, Not connected with each other Hallucination, delusion, grandiose Preoccupied with sexual, political,religious, persecutory ideas Intact memory, oriented to time, place and person Poor Very poor, no insight about their illness Notoriously unreliable

Gen description: Mood, affect, feeling:

Anti depressants induce cycling, hypomania Antidepressants + mood stabilizer Lamotrigine 7 of 8

mania,

PSYCH2 BIPOLAR DISORDERS

Maintainance: therapeutic level

Lithium,

valproate

=

get

• • •

Symptomatically a form of BIID Chronic, fluctuating disturbances with many periods of hypomania and depression Positive history for BID

OTHER MOOD DISTURBANCES DYSTHYMIA • • • • •

• •

Less severe depression Patient complains that they are always depressed Usually early onset 5-6% of general population No gender difference Coexists with anxiety disorder, substance abuse, borderline psychotic disorder Psychosocial Factors: results from personality and ego development and culminates in difficulty adapting to adolescence and early adulthood

C RITERIA • Depressed for most of the day for at least 2 •

•

• •

•

years 2 or more of the following: ◦ Poor appetite/overeating ◦ Insomnia/hyperinsomnia ◦ Low energy/fatigue ◦ Low self-esteem ◦ Poor concentration/difficulty making decisions ◦ Feelings of hopelessness Has never been without the symptoms for > 2 months No major depression/mania/hypomania/mixed episodes Not due to psychotic disorder Not due to substance abuse or GMC

C LINICAL FEATURES : “batugan” • •

Habitual gloom, brooding, lack of joy in life, preoccupation with inadequacy Long-standing, fluctuating, low-grade depression experienced as part of habitual self

DEPRESSIVE • •

•

•

•

DISORDER

NOS

Minor Depressive Disorder ◦ at least 2 but less than 5 symptoms Recurrent Brief Depressive Disorder ◦ less than 2 weeks ◦ at least once a month for 12 months ◦ not associated with menstrual cycle Premenstrual Dysphoric Disorder ◦ late luteal phase dysphoric disorder ◦ mood / behavior / physical symptoms ◦ occurs at specific time in menstrual cycle and resolves between menstrual cycle Post Psychotic Depressive Disorder ◦ Major Depressive Disorder during residual phase ◦ vulnerability to mental illness which lowers self-esteem Bipolar Disorder NOS ◦ Mixed Anxiety Depressive Disorder ◦ Atypical Depression

SECONDARY MOOD DISORDER • •

Mood disorder due to GMC Substance induced mood disorder

Classmates.. ung treatment, dysthymia & cyclothymia at others, paread nlng sa book.. senxa na kng dq na nalagay ung tx ung krugtong ng limpak2 na tables (sna salapi nlng!).. ndi na kc un diniscuss, e parang mas impt ung mga gamot, kc un din nmn ang tnatanong sa exam.. ska ung iba, sa MDD rin... (lulusot pa o!).. tnx2.. God bless! –malta Tnong: paano kbisaduhin ang buong MIMS o PPDr? Sadya bang lakas chamba lng ang medthera? Kung may swerte man, possible ba na kng lhat ay naitama ay considered na “luck”? hehehe..  bangag! Lunes na nmn po.. ansaya! surg path → medthera → pedia (w/dr.dr!).. life!

TREATMENT • Pharmacotherapy •

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

CYCLOTHYMIA •

Lesser BIID Chicha’s grp = junk food’s grp

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