Psychiatry

Lecture 14: Mood Disorders Part 2

Bipolar disorder

 In bipolar disorder, there are episodes of both mania and depression (bipolar I
disorder) or both hypomania and depression (bipolar II disorder).

 There is no simple manic disorder because depressive symptoms eventually occur.

Therefore, one episode of symptoms of mania alone or hypomania plus one episode of
major depression defines bipolar disorder.

 In a hypomanic episode, mild symptoms of mania such as increased sexual interest and
talkativeness are present for at least a 4-day period. In contrast to mania, severe social
or occupational impairment and psychotic symptoms are absent in hypomania and
hospitalization is 'not required.

 Psychotic symptoms, such as delusions, can occur in depression (depression with

psychotic features) as well as in mania.

o In some patients (e.g., poor patients with low access to health care), a mood
disorder with psychotic symptoms can become severe enough to be
Misdiagnosed as schizophrenia.

o In contrast to schizophrenia and schizoaffective disorder, in which patients are

chronically impaired, in mood disorders the patient's mood and functioning
usually return to normal between episodes.

DSM-IV-TR DIAGNOSTIC CRITERIA FOR A MANIC EPISODE

Criterion A.
a distinct period of abnormally and persistently elevated (happiness and physical well-being),
expansive (self-important), or irritable (easily bothered) mood lasting at least l week or less if
hospitalization is necessary

Criterion B.
Symptoms: At least three (four if the mood is only irritable) of the following present

1. lnflated self-esteem or grandiosity

2. Decreased need for sleep
3. Talkativeness or pressured speech
4. Flight of ideas
5. Distractibility
6. Increased activity or agitation
7. Engagement in activities that are likely to have negative consequences
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Criterion C. Symptoms of depression are not present
Criterio D. There is significant distress or impairment in social or occupational functioning.

Criterion E. Symptoms are not caused by a substance or medical condition

Dysthymic disorder and cyclothymic disorder

 Dysthymic disorder involves dysthymia (such as low self-esteem and decreased

productivity), without the extreme symptoms of MDD, such as anhedonia and
suicidality. These symptoms continue over a 2-year period (1 year in children) with no
discrete episodes of illness.

 Cyclothymic disorder involves periods of hypomania and dysthymia occurring over a 2-

year period (1 year in children) with no discrete episodes of illness.
 In contrast to major depressive disorder and bipolar disorder, respectively, dysthymic
disorder and cyclothymic disorder are less severe, nonepisodic, chronic, and never
associated with psychosis or suicide.

The Genetics of Bipolar Disorder

Group Approximate Occurrence (%)

General population 1%

Person who has one bipolar parent or sibling (or 20%

dizygotic twin)
Person who has two bipolar parents 60%

Monozygotic twin of a person with bipolar disorder 75%

Case Example 1

THE PATIENT
A 22-year-old medical student is taken to the emergency department by police when he attempts to
enter a government office building to "have a conference with the President" about conducting a fund
drive to "finance my cure for cancer." When police prevent him from entering the building, he becomes
irritable and hostile and resists attempts to restrain him. In the emergency room, physical examination
is essentially normal. The patient speaks rapidly and his ideas follow each other in rapid succession.
Blood tests do not reveal evidence of substance use. The patient's identical twin brother with whom he
lives notes that the patient has been showing "strange behavior" for the past few weeks. The brother
asks the doctor what is wrong with the patient and whether he himself is at risk for developing the
same symptoms.
COMMENT
The belief that one is important enough to gain a conference with the President and cure cancer is a
grandiose delusion typical of mania. This delusion, combined with the patient's accelerated (pressured)
speech and rapid flow (flight) of ideas, indicates that he is having a manic episode. Anger, irritability,
and hostility are common in a manic episode. Although bipolar I disorder involves episodes of both
mania and major depression, a single episode of mania defines the illness. Although this psychotic
patient could be showing the early signs of schizophrenia, general withdrawal and apathy and paranoid
rather than grandiose delusions are more common in patients with schizophrenia. The risk of this
patient's twin brother also developing bipolar disorder is high; the concordance rate in monozygotic
twins is about 70%.
MANAGEMENT
The emergency room treatment of this psychotic bipolar patient is likely to include benzodiazepines
such as clonazepam (Revotril) and antipsychotics such as olanzapjne (Zyprexa) or risperidone
(Risperdal). His long-term management will be achieved using mood stabilizers such as lithium or
valproic acid (Depakene).

Case Example 2

THE PATIENT
For the past few months, a 28-year-old woman has seemed full of energy and optimism for no obvious
reason. Although she gets only about 5 hours of sleep a night, she has been very productive at work. She
is talkative and sociable and relates that she is having sexual relationships with four different men. A
few years earlier, friends say she was often pessimistic and seemed tired and "washed out." During that
time she continued to work but did not seek out social activities and had little interest in sex. There is
no evidence of a thought disorder, and the patient denies suicidality or hopelessness. Physical
examination, including body weight, is normal.

COMME.NT
This patient's symptoms are characteristic of cyclothymic disorder. This disorder involves periods of
both hypomania (energy, optimism, talkativeness, and hypersexuality) and periods of dysthymia
(pessimism, feeling "washed out," and little interest in socializing or sex). The symptoms persist over at
least a 2-year period with no discrete episodes of illness. In contrast to the bipolar patient in the Case
above , this patient does not show psychotic delusions. Dysthymia is distinguished from depression
here by the absence of suicidal ideation and hopelessness, no change in body weight, and retention of
the ability to function in the work situation.

MANAGEMENT
The most effective long-term treatment for cyclothymic disorder, as for bipolar disorder, is a mood
stabilizer, such as lithium, or an anticonvulsant.

TREATMENT OF MOOD DISORDERS

Overview
1. Depression is successfully treated in most patients.
2. Only about 25% of patients with depression seek and receive treatment.
a. Patients do not seek treatment in part because THEY often believe that mental illness
indicates personal failure or weakness.
b. As in other illnesses, women are more likely than men to seek treatment.
3. Untreated episodes of depression and mania are usually self-limiting and last approximately
6–12 months and 3 months, respectively.
The most effective treatments for the mood disorders are pharmacologic.

Pharmacologic treatment

1. Treatment for depression and dysthymia includes antidepressant agents (e.g., Tricyclics,
selective serotonin and selective serotonin and norepinephrine reuptake inhibitors [SSRIs and
SSNRIs], monoamine oxidase inhibitors [MAOIs],
and stimulants).

2. Mood stabilizers
a. Lithium and anticonvulsants such as carbamazepine (Tegretol) and divalproex (Depakote)
are used to treat bipolar disorder.

b. Mood stabilizers in doses similar to those used to treat bipolar disorder are the primary
treatment for cyclothymic disorder.
3. Atypical antipsychotics such as olanzapine (Zyprexa) and risperidone (Risperdal).
4. Sedative agents such as lorazepam (Ativan) are used to treat acute manic episodes because
they resolve symptoms quickly.

Psychological treatment

1. Psychological treatment for depression and dysthymia includes psychoanalytic,

interpersonal, family, behavioral, and cognitive therapy.
2. Psychological treatment in conjunction with medication is more effective than either type of
treatment alone.

Electroconvulsive therapy (ECT)

The primary indication for ECT is major depressive disorder. It is used when:

1. The symptoms do not respond to antidepressant medications.

2. Antidepressants are too dangerous or have intolerable side effects. Thus, ECT may be
particularly useful for elderly patients.
.Rapid resolution of symptoms is necessary (e.g., the patient is acutely suicidal or psychotic) .3

The End