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Flashcards in Mood Disorders Deck (104)
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31

MDE D's

Duration (most of nearly every day, 2+ weeks) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders)

32

What happened to the bereavement exclusion?

The bereavement exclusion that was used through DSM-IV is not to be found in DSM-5, because recent research has determined that depressions closely preceded by the death or loss of a loved one do not differ substantially from depressions preceded by other stressors (or possibly by none at all).

33

What % of adults will have a manic episode?

~1%

34

Features needed to diagnose manic episode

(1) A mood quality that (2) has existed for a required period of time, (3) is attended by a required number of symptoms, (4) has resulted in a considerable degree of disability, and (5) violates none of the listed exclusions.

35

Quality of mood for manic episode

Some patients with relatively mild symptoms just feel jolly; this bumptious good humor can be quite infectious and may make others feel like laughing with them. But as mania worsens, this humor becomes less cheerful as it takes on a “driven,” unfunny quality that creates discomfort in patients and listeners alike. A few patients will have mood that is only irritable; euphoria and irritability sometimes occur together.

36

Duration of manic episode

The patient must have had symptoms for a minimum of 1 week. This time requirement helps to differentiate manic episode from hypomanic episode.

37

Manic episode symptoms

DIGFAST

38

Symptoms of manic episode not listed in criteria

1. Even during an acute manic episode, many patients have brief periods of depression. These “microdepressions” are relatively common; depending on the symptoms associated with them, they may suggest that the specifier with mixed features is appropriate (p. 161). 2. Patients may use substances (especially alcohol) in an attempt to relieve the uncomfortable, driven feeling that accompanies a severe manic episode. Less often, the substance use temporarily obscures the symptoms of the mood episode. When clinicians become confused about whether the substance use or the mania came first, the question can usually be sorted out with the help of informants. 3. Catatonic symptoms occasionally occur during a manic episode, sometimes causing the episode to resemble schizophrenia. But a history (obtained from informants) of acute onset and previous episodes with recovery can help clarify the diagnosis. Then the specifier with catatonic features may be indicated (p. 100).

39

What if meds, like an SSRI, cause the manic episode?

To count as evidence for either manic or hypomanic episode, DSM-5 requires that the full criteria (not just a couple of symptoms, such as agitation or irritability) be present, and that the symptoms last longer than the expected physiological effects of the treatment.

40

Manic episode impairment

Manic episodes typically wreak havoc on the lives of patients and their associates. Although increasing energy and effort may at first actually improve productivity at work (or school), as mania worsens a patient becomes less and less able to focus attention. Friendships are strained by arguments. Sexual entanglements can result in disease, divorce, and unwanted pregnancy. Even when the episode has resolved, guilt and recriminations remain behind.

41

Manic episode impairment

Manic episodes typically wreak havoc on the lives of patients and their associates. Although increasing energy and effort may at first actually improve productivity at work (or school), as mania worsens a patient becomes less and less able to focus attention. Friendships are strained by arguments. Sexual entanglements can result in disease, divorce, and unwanted pregnancy. Even when the episode has resolved, guilt and recriminations remain behind.

42

Exclusions for manic episode

The exclusions for manic episode are the same as for major depressive episode. General medical conditions such as hyperthyroidism can produce hyperactive behavior; patients who misuse certain psychoactive substances (especially amphetamines) will appear speeded up and may report feeling strong, powerful, and euphoric.

43

Essential featuers for manic episode

Patients in the throes of mania are almost unmistakable. These people feel euphoric (though sometimes they’re only irritable), and there’s no way you can ignore their energy and frenetic activity. They are full of plans, few of which they carry through (they are so distractible). They talk and laugh, and talk some more, often very fast, often with flight of ideas. They sleep less than usual (“a waste of time, when there’s so much to do”), but feel great anyway. Grandiosity is sometimes so exaggerated that they become psychotic, believing that they are exalted personages (monarchs, rock stars) or that they have superhuman powers. With deteriorating judgment (they spend money unwisely, engage in ill- conceived sexual adventures), functioning becomes impaired, often to the point they must be hospitalized to force treatment or for their own protection or that of other people.

44

Manic Episode D's

• Duration (most of nearly every day, 1+ weeks) • Distress or disability (work/ educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, schizoaffective disorder, neurocognitive disorders, hypomanic episodes, cyclothymia)

45

Comparing hypomanic and manic episode (table)

INSERT TABLE

46

Hypomanic episode requires

Hypomanic episode requires (1) a mood quality that (2) has existed for a required period of time, (3) is attended by a required number of symptoms, (4) has resulted in a considerable degree of disability, and (5) violates none of the listed exclusions. Table 3.1 compares the features of manic and hypomanic episodes.

47

Quality of mood in hypomanic episode

The quality of mood in hypomanic episode tends to be euphoric without the driven quality present in manic episode, though mood can instead be irritable. However described, it is clearly different from the patient’s usual nondepressed mood.

48

Duration of hypomanic episode

The patient must have had symptoms for a minimum of 4 days—a marginally shorter time requirement than that for manic episode.

49

Symptoms in hypomanic episode

As with manic episode, in addition to the change in mood (euphoria or irritability), the patient must also have an increase in energy or activity level—but again, only for 4 days. Then at least three symptoms from the same list must be present to an important degree (and represent a noticeable change) during this 4 days. If the patient’s abnormal mood is irritable and not elevated, four symptoms are required. Note that hypomanic episode precipitated by treatment can be adduced as evidence for, say, bipolar II disorder—if it persists longer than the expected physiological effects of the treatment. The sleep of hypomanic patients may be brief, and activity level may be increased, sometimes to the point of agitation. Although the degree of agitation is less than in a manic episode, hypomanic patients can also feel driven and uncomfortable. Judgment deteriorates, and may lead to untoward consequences for finances or for work or social life. Speech may become rapid and pressured; racing thoughts or flight of ideas may be noticeable. Easily becoming distracted can be a feature of hypomanic episode. Heightened self- esteem is never so grandiose that it becomes delusional, and hypomanic patients are never psychotic. In addition to the DSM-5 criteria, note that in hypomanic episode, as in manic episode, substance use is common.

50

Impairment in hypomanic episode

How severe can the impairment be without qualifying as a manic episode? This is to some extent a judgment call for the practitioner. Lapses of judgment, such as spending sprees and sexual indiscretions, can occur in both manic and hypomanic episodes— but, by definition, only the patient who is truly manic will be seriously impaired. If behavior becomes so extreme that hospitalization is needed or psychosis is evident, the patient can no longer be considered hypomanic, and the label must be changed

51

Exclusions for hypomanic episode

The exclusions are the same as those for manic episode. General medical conditions such as hyperthyroidism can produce hyperactive behavior; patients who misuse certain substances (especially amphetamines) will appear speeded up and may also report feeling strong, powerful, and euphoric.

52

Essential featuers of hypomanic episode

Hypomania is “mania lite”—many of the same symptoms, but never to the same outrageous degree. These people feel euphoric or irritable and they experience high energy or activity. They are full of plans, which, despite some distractibility, they sometimes actually implement. They talk a lot, reflecting their racing thoughts, and may have flight of ideas. Judgment (sex and spending) may be impaired, but not to the point of requiring hospitalization for their own protection or that of others. Though the patients are sometimes grandiose and self- important, these features never reach the point of delusion. You would notice the change in such a person, but it doesn’t impair functioning; indeed, sometimes these folks get quite a lot done!

53

The D's for hypomanic episode

• Duration (most of nearly every day, 4+ days) • Disability (work/educational, social, and personal functioning are not especially impaired) • Differential diagnosis (substance use and physical disorders, other bipolar disorders)

54

MDD prevalence

~7%

55

MDD Female:Male ratio

~2:1

56

Average length of MDE

6 to 9 months (but range from weeks to years)

57

How many patients with a MDE have another?

About half

58

To count as a second episode of major depression, how much time needs to pass between episodes?

Two months

59

What percent of patients with MDD commit suicide?

~4%

60

A note on somatic symptom disorder

There’s a situation in which I like to be extra careful about diagnosing MDD. That’s when a patient also has somatic symptom disorder (see p. 251). The problem is that many people who seem to have too many physical symptoms can also have mood symptoms that closely resemble major depressive episodes (and sometimes manic episodes). Over the years, I’ve found that these people tend to get treatment with medication, electroconvulsive therapy (EcT), and other physical therapies that don’t seem to help them much— certainly not for long. I’m not saying that drugs never work; I maintain only that if you encounter a patient with somatic symptom disorder who is depressed, other treatments (such as cognitive- behavioral therapy or other forms of behavior modification) may be more effective and less fraught with complications.
 

Reminds me of patient MB on 4S as a PGY2 (with Dr. Lenet)