BipolarD, DepressiveD

Question 1

Substance/medication-induced psychotic disorder

Answer 1

• Individual has delusions and/or hallucinations
• Evidence from history that effects are due to physiological effects of substance
• Delusions develop soon after substance use
• Involved substance is capable of producing delusions and/or hallucinations

Question 2

Psychotic disorder due to somatic disease

Answer 2

• Patient has hallucinations or delusions
• There is evidence from history, physical examination or laboratory finding that the psychosis is directly pathophysiological effects of somatic disease.

Question 3

Differential diagnosis of D due to SD

Answer 3

• Psychotic disorder due to somatic diseases with substance induced psychotic disorder
• individuals who have diseases take medicines - side effects may cause the psychotic symptoms

Question 4

Bipolar disorders

Answer 4

• Characterised by persistent disturbances in mood, which is either depressed or elevated, expansive or irritable
• Mood disturbances are accompanied by specific life changes in patient’s volition and vegetative functions
  (sleep, appetite, sex), thinking, attention, interests, outlooks and expectations.

Question 5

BD presentation

Answer 5

• Cyclical course defined by mood episodes followed by lucid episodes of euthymia and relatively preserved functioning OR
• By persistent subsyndromal (not enough for diagnosis) mood dysregulation (cyclothymic disorder)

Question 6

Types of mood episodes of BD

Answer 6

3 types

1. Manic episodes
2. Hypomanic episodes
3. Major depressive episodes

Question 7

1. Manic episodes of BD

Answer 7

Are distinct periods of abnormally and persistently elevated, expansive (i.e. hyperthymia) or irritable mood (dysphoria) and persistently increased goal-directed activity or energy (hyperbola) most of the day nearly everyday AND
- Last at least 1 week

Question 8

Symptoms of manic episodes of BD

Answer 8

1. Inflated self-esteem or grandiosity - they feel extraordinarily superior to peers, boasting, delusion of wealth
2. Decreased need for sleep. e.g. couple hours to feel energetic
3. More talkative than usual or pressure to keep talking (convos with strangers, difficult to interrupt)
4. Fight of ideas or subjective experience that thoughts are racing - listener can’t catch up, thoughts running
5. Distractibility (attention easily drawn to unimportant or irrelevant stimuli)
6. Increased in goal directed activity or agitation (e.g. participation in multiple social, occupational, sexual or religious activities, results in increased psychomotor activity - restlessness)

LIMITLESS - Hospitalisation may be required

Question 9

2. Hypomanic episodes

Answer 9

• Are distinct periods of persistently elevated, expansive or irritable mood and persistently increased goal-directed activity or energy, lasting throughout at least 4 days accompanied by at least 3 additional manic symptoms
• Not associated with marked impairment in functioning and do not require hospitalisation

Question 10

Major depressive episodes

Answer 10

• are distinct periods, lasting at least two weeks, during which 5 or more of the following symptoms are present most of the day.
  1. Depressed mood
  2. Marked diminished interest or pleasure in most activities
  3. Significant weight change or change in appetite
  4. Insomnia or hypersomnia
  5. Psychomotor agitation or retardation (patient may unable to sit still, slowed speech and bodily movements)
  6. Fatigue or loss of energy
  7. Feeling of worthlessness or excessive inappropriate guilt
  8. Diminished ability to think or concentrate or indecisiveness.
  9. Recurrent thoughts of death and suicide

Question 11

Classification of BDs

Answer 11

1. Bipolar I disorder (BDI) - cyclical
2. Bipolar II disorder (BDII) - cyclical
3. Cyclothymic disorder - chronic

Question 12

Functional consequences of BDs

Answer 12

• Manic episodes have a devastating impact on the patient’s capabilities to study, work, socialise while depressive episodes impede their ability to attain previous levels of functioning.
• This accounts for a high rates of disability associated with the disorder
• Bipolar disorders are associated with a high suicide risk (10% of all patients)

Question 13

Etiopathogensis of BD. Biological factors

Answer 13

• Genetics - twins
• Neuroanatomical and neurophysiologic changes - decreased metabolism in certain brain areas such as hippocampus
• Neurotransmitter dysfunction - dopamine, serotonin
• Seasonal and circadian rhythms - dysregulation of these rhythms is relevant to mood disorders

Question 14

Etiopathogenesis of BD. Psychological and social factors

Answer 14

• Psychosocial stressors. such as adverse life events

- “kindling” - Phenomenon in which onset of mood episode trigger the onset of subsequent mood episodes

Question 15

DD of BD

Answer 15

• Depressive disorders
• Often depressed patients fault to remember or intentionally avoid disclosing previous hypomanic or manic episodes
  Others to consider
• Substance induced
• Mood disorders due to somatic disease
• Schizophrenia and Schizoactive disorder
• Adjustment disorders with depressed mood
• Anxiety, personality and eating disorders with prominent mood features.

Question 16

Comorbidity during BD

Answer 16

• Obesity and metabolic syndrome

- suffer more frequently from eating disorders, alcohol abuse, substance use and increased risk of suicide.

Question 17

Treatment of BD

Answer 17

1. Pharmacotherapy - more than one mood stabiliser, atypical Aps. avoid high intensity typical AP,
2. Psychotherapy/Sociotherapy - educating patients about nature of their disorder

Question 18

Depressive disorders (DD)

Answer 18

• Are characterised by the occurrence of major depressive episodes or by chronic subthreshold depression in the absence of manic and hypomanic episodes

Question 19

Classifications of DD

Answer 19

They are generally classified as either

1. Major depressive disorder (MDD)
2. Persistent depressive disorder (PDD)
3. Premenstrual dysphoric disorder

Question 20

1. Major depressive DD

Answer 20

Characterised by one or more major depressive episodes, usually followed by periods of preserved social and occupational functioning
- Symptoms are same as bipolar depressive stage

Question 21

2. Persistent depressive disorder

Answer 21

Characterised by persistently depressed mood most of the day, for more days than not, for period of at least 2 years accompanied by additional depressive symptoms that may or may not meet the full diagnostic criteria for major depressive episode

Question 22

3. Premenstural dysphoric syndrome

Answer 22

• Characterised by prominent mood symptoms that occur during the final week before the onset of menses that resolve or become minimal in the week postmenses during most menstrual cycles during the preceding year
  These include

Mood lability, irritability, depressed mood, anxiety and tension. Additionally

• Decreased interest in usual activities, concentration difficulties, fatigability, appetite changes, sleep disturbances
• Physical symptoms - breast tenderness, bloating

Question 23

Development and course of DD

Answer 23

• MDD and Premenstrual dysphoric syndrome have a cyclic course with mood episodes generally separated by periods of euthymia and preserved functioning.
• Persistent depressive disorder is chronic
• Substance induced depressive disorders and mood disorders due to somatic diseases tend to follow the course of substance sue and medical condition, respectively.

Question 24

Differential diagnosis of DD

Answer 24

Same as bipolar

Question 25

Treatment of DD

Answer 25

• SSRIS plus benzodiazepines may be needed to control anxiety, insomnia, psychomotor agitation and suicide risk
• Mood stabilisers in frequent episodes or when bipolar disorder is clinically suspected.