Cyclothymic D/O + rest of bipolar chapter (DSM) Flashcards
criterion A for cyclothymic disorder
for at least TWO YEARS (at least ONE in kids and teens) there have been NUMEROUS periods with hypomanic symptoms that do NOT meet criteria for a hypomanic episode and numerous episodes with depressive symptoms that do not meet criteria for a major depressive episode
criterion B for cyclothymic disorder
during the required 2 year period (1 year in kids and teens), the hypomanic and depressive periods have been present for at least HALF THE TIME and the individual has not been WITHOUT the symptoms for more than TWO MONTHS at a time
criterion C for cyclothymic disorder
criteria for a major depressive, manic or hypomanic episode have NEVER BEEN MET
criterion D for cyclothymic disorder
the symptoms in criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or other specified or unspecified schizophrenia spectrum and other psychotic disorder
criterion E for cyclothymic disorder
symptoms are not attributable to the physiological effects of a substance or another medical condition
criterion F for cyclothymic disorder
symptoms cause CLINICALLY SIGNIFICANT distress or impairment in social, occupational or other important areas of functioning
what specifier may accompany cyclothymic disorder
with anxious distress
what is the essential feature of cyclothymic disorder
CHRONIC, FLUCTUATING mood disturbance involving numerous periods of hypomanic symptoms and periods of depressive symptoms that are distinct from each other
hypomanic sx are insufficient in number, severity, pervasiveness or duration to meet full criteria for a hypomanic episode (same for the depressive symptoms)
what is the time criteria for cyclothymic disorder
a two year period in which person has not been without symptoms for more than 2 months at a time and has symptoms for at least half the time
what aspect of cyclothymic disorder may lead to the impairment required to make the diagnosis
may develop as a result of long periods of cyclical, often unpredictable mood changes i.e person may be regarded as temperamental, moody, unpredictable, inconsistent or unreliable
what is the lifetime prevalence of cyclothymic disorder
0.4-1%
(prevalence in mood disorders clinic 3-5%)
is cyclothymic disorder more common in males or females
equally common in both
when does cyclothymic disorder usually begin
in adolescence or early adulthood
sometimes considered a temperamental predisposition to other disorders in bipolar section of DSM
what is the usual course of cyclothymic disorder
insidious onset and persistent course
what is the risk that someone with cyclothymic disorder will eventually develop bipolar I or II disorder
15-50% risk
among children with cyclothymic disorder what is the mean age of onset
6.5 years
what disorders are more common amongst those who have a first degree relative with cyclothymic disorder
MDD
bipolar I
bipolar II
may also be an increased familial risk of SUDs
cyclothymic disorder may be more common in those with a first degree relative with bipolar I
ddx of cyclothymic disorder
bipolar and related disorder due to another medical condition
depressive disorder due to another medical condition
sub/med induced bipolar or depressive disorder
bipolar I with rapid cycling
bipolar II with rapid cycling
borderline PD
can both cyclothymic disorder and borderline PD be diagnosed in the same person
yes, if criteria for both are met
list common comorbidities with cyclothymic disorder
SUDs
sleep disorders
ADHD
criterion A for substance/medication induced bipolar and related disorder
a prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by elevated, expansive or irritable mood with or without depressed mood, or markedly diminished interest or pleasure in all, or almost all activities
criterion B for substance/medication induced bipolar and related disorder
there is evidence from the history, physical exam, or lab findings of both of the below:
- the symptoms in criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication
AND - the involved substance/med is capable of producing the symptoms in criterion A
criterion C for substance/medication induced bipolar and related disorder
disturbance not better explained by a bipolar or related disorder that is not substance/med related
what evidence might suggest that the substance/medication induced bipolar and related disorder is in fact not related to a substance or med
the symptoms precede the onset of the sub/med use
the symptoms persist for a substantial period of time (i.e about 1 month) after the cessation of acute withdrawal or severe intox
or there is other evidence suggesting the existence of an independent bipolar type illness unrelated to substances
criterion D for substance/medication induced bipolar and related disorder
disturbance does not occur exclusively during the course of delirium
criterion E for substance/medication induced bipolar and related disorder
disturbance causes clinically significant distress or impairment in social, occupational or other areas of functioning
what specifiers are there for substance/medication induced bipolar and related disorder
with onset during intoxication
with onset during withdrawal
what is the key exception for substance/medication induced bipolar and related disorder
case of hypomania/mania that occurs after antidepressant/ECT use and persists beyond the physiological effects of the med/treatment–> this is considered an indicator of true bipolar disorder and not a sub/med induced one
what substances and medications are typically considered to be associated with substance/medication induced bipolar and related disorder
stimulant class of drugs
phencyclidine
steroids
(others continue to emerge, like bath salts)
how might a phencyclidine induced mania initially present
a delirium with affective features which becomes an atypically appearing manic or mixed manic state
over what time frame after ingestion would phencyclidine related bipolar disorder present
quickly–> usually within hours or at the most, a few days, or ingestion or inhalation
how quickly would a stimulant induced bipolar picture present
minutes to 1 hour after one or several ingestions or injections
how long does a stimulant induced bipolar picture typically last
typically only 1-2 days and the resolves
how might a steroid or other immunosuppresant induced mania present
usually follows several days of steroid ingestion
higher doses appear to have greater likelihood of producing mania/bipolar sx
ddx substance/medication induced bipolar and related disorder
other bipolar disorders
substance intoxication
substance induced delirium
medication side effect
criterion A for bipolar and related disorder due to another medical condition
a prominent and persistent period of abnormally elevated, expansive or irritable mood and abnormally increased activity or energy that predominates in the clinical picture
criterion B for bipolar and related disorder due to another medical condition
there is evidence from the history, physical examination or lab findings that the disturbance is the direct pathophysiological consequence of another medical condition
criterion C for bipolar and related disorder due to another medical condition
the disturbance is not better explained by another mental disorder
criterion D for bipolar and related disorder due to another medical condition
disturbance does not occur exclusively during the course of a delirium
criterion E for bipolar and related disorder due to another medical condition
disturbance causes clinically significant distress or impairment etc
OR
necessitates hospitalization to prevent harm to self or others or there are psychotic features
what are the specifiers assoc with bipolar and related disorder due to another medical condition
with manic features–> full criteria not met for manic or hypomanic episode
with manic-or-hypomanic like episode–> full criteria are met except criterion D for a manic episode and except for criterion F for hypomanic episode
with mixed features–> sx of depression also present but do not predominate in the clinical picture
what are the best known medical conditions that can cause bipolar and related disorder due to another medical condition
cushing’s disease
multiple sclerosis
stroke and TBI
*the list of the conditions that can cause mania/hypomania type picture is “never complete”–> “the clinicians best judgment is the essence of this diagnosis”
how does bipolar and related disorder due to another medical condition usually present
usually onset is ACUTE or SUBACUTE within first weeks or month of the onset of the associated medical condition
*not always the case if related to worsening or relapse of chronic illness
may remit just before or just after the medical condition remits, especially when tx of mania/hypomanic sx is effective
if the cushings disease is cured or arrested, do we generally think the mania/hypomania will recur or no?
believed generally that it will not recur
if mania/hypomania occurs in the context of static brain injuries or other CNS diseases, do we generally think the mood sx will recur or no?
may be episodic/recurring in these situations
ddx bipolar and related disorder due to another medical condition
delirium
catatonia
acute anxiety
med-induced manic or depressive syndromes
when would you use the dx “other specified bipolar and related disorder”
presentations in which symptoms characteristic of a bipolar and related disorder that cause clinically significant distress or impairment in social, occupational or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the bipolar and related class
i.e short duration hypomanic episodes and MDEs
mixed features associated with a MDE have been found to be a significant risk factor for what
development of bipolar I or II
for those with rapid cycling, must there be a certain length of time between mood episodes?
no minimum time between episodes if sequential episodes are on opposite polarities (i.e hypomanic to depressed)–> if the episodes are of the same polarity, must be demarcated by either partial or full remissions of at least TWO MONTHS between them
what makes “melancholic features” different from just regular depression/anhedonia
there is a near-complete absence of the capacity for pleasure not merely a diminution –> experienced as qualitatively different from that experienced during a non-melancholic episode
psychomotor changes are nearly always present and often noted by others
what % of women will experience the onset of a MDE during pregnancy or in the weeks or months following delivery
3-6%
what % of “postpartum” depression actually begins before delivery
50%
postpartum mood episodes (either depressed or manic) with PSYCHOTIC features occur how commonly
1/500 ot 1/1000 deliveries
risk of postpartum episodes with psychotic features is particularly increased in which women
women with prior postpartum mood episodes
those with prior hx of depressive or bipolar disorder
those with family history of bipolar disorders
infanticide is most often associated with what psychiatric symptoms in a post partum woman
postpartum psychotic episodes that are characterized by COMMAND hallucinations to kill the infant or delusions that the infant is possessed
once a woman has had a postpartum episode with psychotic features what is the risk of recurrence with each subsequent delivery
between 30-50%
what does it mean to have a “Seasonal pattern” as per the DSM specifier
a lifetime pattern of mood episodes where there is a regular seasonal pattern of AT LEAST ONE types of episode (i.e mania, hypomania or depression)–> the other types of episodes may be have a seasonal pattern
ie seasonal manias but not depressions
full remissions also occur at characteristic times of year
define “in partial remission” in bipolar disorders
symptoms of immediately preceeding manic, hypomanic or major depressive episode ARE PRESENT but full criteria are not met, or there is a period of LESS THAN TWO MONTHS without any significant symptoms of a manic, hypomanic or MDE following the end of such an episode
define “in full remission” in bipolar disorders
during the past TWO MONTHS, no significant signs or symptoms of the disturbance were present
define mild manic episode
minimum symptom criteria met for manic episode
define moderate manic episode
very significant increase in activity or impairment in judgment
define severe manic episode
almost continual supervision required in order to prevent physical harm to self or others
define mild MDE
“Few, if any, symptoms in excess of those required to meet the diagnostic criteria are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning.”
define moderate MDE
“The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe.””
define severe MDE
“The number of symptoms is substantially in excess of those required to make the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning.”
