Depression And Bipolar Disorder
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Depression and Bipolar Disorder (kaplan & sadock) Resume Dr liza
Mood is a pervasive and sustained feeling tone that is experienced internally and that influences a person's behavior and perception of the world. Affect is the external expression of mood. Mood can be: normal, elevated, or depressed. Healthy persons experience a wide range of moods and have an equally large repertoire of affective expressions; they feel in control of their moods and affects.
Mood disorders are a group of clinical conditions characterized by a loss of that sense of control and a subjective experience of great distress. Patients with elevated mood demonstrate expansiveness, flight of ideas, decreased sleep, and grandiose ideas. Patients with depressed mood experience a loss of energy and interest, feelings of guilt, difficulty in concentrating, loss of appetite, and thoughts of death or suicide. Other signs and symptoms of mood disorders include change in activity level, cognitive abilities, speech, and vegetative functions (e.g., sleep, appetite, sexual activity, and other biological rhythms). These disorders virtually always result in impaired interpersonal, social, and
Patients
afflicted with only major depressive episodes are said to have major depressive disorder or unipolar depression. Patients with both manic and depressive episodes or patients with manic episodes alone are said to have bipolar disorder. The terms unipolar mania and pure mania are sometimes used for patients who are bipolar, but who do not have depressive episodes.
Three additional categories of mood disorders are: Hypomania cyclothymia dysthymia. Hypomania is an episode of manic symptoms that does not meet the full text revision of the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) criteria for manic episode. Cyclothymia and dysthymia are defined by DSM-IV-TR as disorders that represent less severe forms of bipolar disorder and major depression, respectively.
Incidence and Prevalence Mood disorders are common. In the most recent surveys, major depressive disorder has the highest lifetime prevalence (almost 17 percent) of any psychiatric disorder. The lifetime prevalence rate of different forms of DSMIV-TR unipolar depressive disorder, according to the eight major community surveys, are shown in Table 15.1-1. The yearly incidence of a major depression is 1.59 percent (women, 1.89 percent; men, 1.10 percent). The lifetime prevalence rates of different clinical forms of bipolar disorder are shown in Table 15.1-2. The annual incidence (number of new cases) of a major depressive episode is 1.59 percent (women, 1.89 percent; men, 1.10 percent). The annual incidence of bipolar illness is less than 1 percent, but it is difficult to estimate, because milder
DSM-IV-TR Criteria for Major Depressive Episode 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 due to a general medical condition, or mood-incongruent delusions or hallucinations.
– depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood – 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
– 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 gains. – insomnia or hypersomnia nearly every day – psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
– psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) – fatigue or loss of energy nearly every day – feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) – diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) – 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
The symptoms do not meet criteria for a mixed episode. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months o are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
DSM-IV-TR
Criteria for Manic Episode A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: – inflated self-esteem or grandiosity – decreased need for sleep (e.g., feels rested after only 3 hours of sleep) – more talkative than usual or pressure to keep
– flight of ideas or subjective experience that thoughts are racing – distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) – increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation – excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
The symptoms do not meet criteria for a mixed episode. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm
The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of bipolar I disorder. (From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association
DSM-IV-TR
Criteria for Hypomanic
Episode A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
– flight of ideas or subjective experience that thoughts are racing – distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) – increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation – excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. The disturbance in mood and the change in functioning are observable by others. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication,
DSM-IV-TR Criteria for Mixed Episode The criteria are met both for a manic episode and for a major depressive episode (except for duration) nearly every day during at least a 1week period. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). Note: Mixed-like episodes that are clearly caused by somatic antidepressant treatment
DSM-IV-TR Criteria for Severity/Psychotic/ Remission Specifiers for Current (or Most Recent) Major Depressive Episode Note: Code in fifth digit. Mild, moderate, severe without psychotic features, and severe with psychotic features can be applied only if the criteria are currently met for a major depressive episode. In partial remission and in full remission can be applied to the 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. Mild: Few, if any, symptoms in excess of those required to make the diagnosis and symptoms result in only minor impairment in occupational functioning or in usual social activities or relationships with others. Moderate: Symptoms or functional impairment between mild and severe.
Severe without psychotic features: Several symptoms in excess of those required to make the diagnosis, and symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others. Severe with psychotic features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or moodincongruent: Mood-congruent psychotic features: Delusions or hallucinations whose content is entirely consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Mood-incongruent psychotic features: Delusions or hallucinations whose content does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to
Mood-incongruent psychotic features: Delusions or hallucinations whose content does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to depressive themes), thought insertion, thought broadcasting, and delusions of control. In partial remission: Symptoms of a major depressive episode are present but full criteria are not met, or there is a period without any significant symptoms of a major depressive episode lasting less than 2 months following the end of the major depressive episode. (If the major depressive episode was superimposed on dysthymic disorder, the diagnosis of dysthymic disorder alone is given once the full criteria for a major depressive episode are no longer met.) In full remission: During the past 2 months, no
DSM-IV-TR Criteria for Severity/Psychotic/ Remission Specifiers for Current (or Most Recent) Manic Episode Note: Code in fifth digit. Mild, moderate, severe without psychotic features, and severe with psychotic features can be applied only if the criteria are currently met for a 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. 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 or others. Severe with psychotic features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-
Mood-congruent psychotic features: Delusions or hallucinations whose content is entirely consistent with the typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Mood-incongruent psychotic features: Delusions or hallucinations whose content does not involve typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled. In partial remission: Symptoms of a manic episode are present but full criteria are not met, or there is a period without any significant symptoms of a manic episode lasting less than 2 months following the end of the manic episode. In full remission: During the past 2 months no
Mood is a pervasive and sustained feeling tone that is experienced internally and that influences a person's behavior and perception of the world. Affect is the external expression of mood. Mood can be: normal, elevated, or depressed. Healthy persons experience a wide range of moods and have an equally large repertoire of affective expressions; they feel in control of their moods and affects.
Mood disorders are a group of clinical conditions characterized by a loss of that sense of control and a subjective experience of great distress. Patients with elevated mood demonstrate expansiveness, flight of ideas, decreased sleep, and grandiose ideas. Patients with depressed mood experience a loss of energy and interest, feelings of guilt, difficulty in concentrating, loss of appetite, and thoughts of death or suicide. Other signs and symptoms of mood disorders include change in activity level, cognitive abilities, speech, and vegetative functions (e.g., sleep, appetite, sexual activity, and other biological rhythms). These disorders virtually always result in impaired interpersonal, social, and
Patients
afflicted with only major depressive episodes are said to have major depressive disorder or unipolar depression. Patients with both manic and depressive episodes or patients with manic episodes alone are said to have bipolar disorder. The terms unipolar mania and pure mania are sometimes used for patients who are bipolar, but who do not have depressive episodes.
Three additional categories of mood disorders are: Hypomania cyclothymia dysthymia. Hypomania is an episode of manic symptoms that does not meet the full text revision of the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) criteria for manic episode. Cyclothymia and dysthymia are defined by DSM-IV-TR as disorders that represent less severe forms of bipolar disorder and major depression, respectively.
Incidence and Prevalence Mood disorders are common. In the most recent surveys, major depressive disorder has the highest lifetime prevalence (almost 17 percent) of any psychiatric disorder. The lifetime prevalence rate of different forms of DSMIV-TR unipolar depressive disorder, according to the eight major community surveys, are shown in Table 15.1-1. The yearly incidence of a major depression is 1.59 percent (women, 1.89 percent; men, 1.10 percent). The lifetime prevalence rates of different clinical forms of bipolar disorder are shown in Table 15.1-2. The annual incidence (number of new cases) of a major depressive episode is 1.59 percent (women, 1.89 percent; men, 1.10 percent). The annual incidence of bipolar illness is less than 1 percent, but it is difficult to estimate, because milder
DSM-IV-TR Criteria for Major Depressive Episode 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 due to a general medical condition, or mood-incongruent delusions or hallucinations.
– depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood – 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
– 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 gains. – insomnia or hypersomnia nearly every day – psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
– psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) – fatigue or loss of energy nearly every day – feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) – diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) – 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
The symptoms do not meet criteria for a mixed episode. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months o are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
DSM-IV-TR
Criteria for Manic Episode A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: – inflated self-esteem or grandiosity – decreased need for sleep (e.g., feels rested after only 3 hours of sleep) – more talkative than usual or pressure to keep
– flight of ideas or subjective experience that thoughts are racing – distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) – increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation – excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
The symptoms do not meet criteria for a mixed episode. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm
The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of bipolar I disorder. (From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association
DSM-IV-TR
Criteria for Hypomanic
Episode A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
– flight of ideas or subjective experience that thoughts are racing – distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) – increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation – excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. The disturbance in mood and the change in functioning are observable by others. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication,
DSM-IV-TR Criteria for Mixed Episode The criteria are met both for a manic episode and for a major depressive episode (except for duration) nearly every day during at least a 1week period. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). Note: Mixed-like episodes that are clearly caused by somatic antidepressant treatment
DSM-IV-TR Criteria for Severity/Psychotic/ Remission Specifiers for Current (or Most Recent) Major Depressive Episode Note: Code in fifth digit. Mild, moderate, severe without psychotic features, and severe with psychotic features can be applied only if the criteria are currently met for a major depressive episode. In partial remission and in full remission can be applied to the 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. Mild: Few, if any, symptoms in excess of those required to make the diagnosis and symptoms result in only minor impairment in occupational functioning or in usual social activities or relationships with others. Moderate: Symptoms or functional impairment between mild and severe.
Severe without psychotic features: Several symptoms in excess of those required to make the diagnosis, and symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others. Severe with psychotic features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or moodincongruent: Mood-congruent psychotic features: Delusions or hallucinations whose content is entirely consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Mood-incongruent psychotic features: Delusions or hallucinations whose content does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to
Mood-incongruent psychotic features: Delusions or hallucinations whose content does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to depressive themes), thought insertion, thought broadcasting, and delusions of control. In partial remission: Symptoms of a major depressive episode are present but full criteria are not met, or there is a period without any significant symptoms of a major depressive episode lasting less than 2 months following the end of the major depressive episode. (If the major depressive episode was superimposed on dysthymic disorder, the diagnosis of dysthymic disorder alone is given once the full criteria for a major depressive episode are no longer met.) In full remission: During the past 2 months, no
DSM-IV-TR Criteria for Severity/Psychotic/ Remission Specifiers for Current (or Most Recent) Manic Episode Note: Code in fifth digit. Mild, moderate, severe without psychotic features, and severe with psychotic features can be applied only if the criteria are currently met for a 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. 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 or others. Severe with psychotic features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-
Mood-congruent psychotic features: Delusions or hallucinations whose content is entirely consistent with the typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Mood-incongruent psychotic features: Delusions or hallucinations whose content does not involve typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled. In partial remission: Symptoms of a manic episode are present but full criteria are not met, or there is a period without any significant symptoms of a manic episode lasting less than 2 months following the end of the manic episode. In full remission: During the past 2 months no
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