DSM V and differentials

Question 1

Hypomanic episode

Answer 1

1. Elevated, expansive or irritable mood and increased activity/ energy that is abnormal and persistent over at least 4 consecutive days and present most of the day, nearly every day
2. During the mood and energy/activity level changes, three or more of the following functional changes are present (4 if mood is irritable)
   
   1. Improved self esteem/grandiosity
   2. Decreased need for sleep
   3. More talkative/pressured speech
   4. Flight of ideas or “thoughts are racing”
   5. Distractibility (attention too easily drawn to irrelevant external stimuli)
   6. Increase in goal directed activity or psychomotor agitation
   7. Excessive involvement in activities that have a high potential for painful consequences (unrestrained spending, sexual indiscretions, foolish investments)
3. Not normal for the person/not a personality variant: The episode is associated with unequivocal change in functioning that is uncharacteristic od the individual when not symptomatic
4. Others can notice the change in mood and function
   
   1. Not severe enough to be mania: no impairment in socio-occupational functioning, hospitalization, or presence of psychotic features
5. Not attributable to the physiological effects of a substance

Question 2

Manic episode

Answer 2

1. Period of elevated, expansive or irritable mood + increased activity and energy that is abnormal and persistent for at least one week, most of the day, nearly every day (or any duration if hospitalization is necessary)
2. During period of mood + activity increase, three (or more) of the following behavioural changes must be present (4 if change in mood is irritability)
   
   1. Inflated self esteem/grandiosity
   2. Decreased need for sleep
   3. More talkative than usual or pressure to keep talking
   4. flight of ideas or “thoughts racing”
   5. Distractibility (poor attention)
   6. Increased goal-oriented activity or spcyhomotor agitation
   7. excessive involvement in activity that have a potential for painful consequences (unrestrained spending, sexual indiscretion, foolish business investments)
3. The mood disturbance is sufficiently severe = marked socio-occupational functioning OR require hospitalization OR presence of psychotic features
4. Episode is not attributable to the physiological effects of a substance or to another medical condition

Question 3

Bipolar major depression

Answer 3

1. Diagnostic criteria of major depressive episode
   
   1. Five or more of the following symptoms have been present in the same two-week period and present a change from previous functionoing; at least one of the five symptoms is either (a) depressed mood and (b) loss of interest/pleasure
      
      1. ​Depressed mood “feel sad/empty/hopeless” or observed by others to be depressed (tearful, irritable)
      2. Loss of interest or pleasure in all or almost all activities
      3. Significant weight loss when not dieting OR weight gain (change of >5% in a month), OR decrease/increase in appetite
      4. Insomnia or hypersomnia. When awake at night, patient usually has ruminations surrounding the past
      5. Psychomotor agitation or retardation that is observable
      6. Fatigue or loss of energy
      7. Feelings of worthlessness, excessive/inappropriate guilt (which may be delusional proportions)
      8. Diminished ability to think/concentrate/make decisions (pseudo-dementia)
      9. Recurrent thoughts of death, suicidal ideation +/- plan
   2. Syptoms cause clinically significant distress or impairment in functioning
   3. The episode is not attributable to effects of substance or another medical condition (e.g. dementia)
2. The occurence of the major depressive episode is not better explained by other psychiatric illness: schizoaffective disorder, schizophreniform disorder, delusional disorder etc

Note: responses to significant loss/stress can also include feelings of intense sadness,r umination, insomnia, poor appetite and weight loss noted in criterion 1, which may resemble a depressive episode. Although such symptoms may be understandable in the context, the presence of Major depression in addition to the normal response to a significant loss needs to be carefully considered. This decision requires the exercise of clinical judgement based on individual’s history and the cultural norms for the expression of distress

Specify if bipolar MDD is present with:

• Anxious distress
• Mixed features
• Rapid cycling
• Melancholic features
• Atypical features
• Psychotic features
• Catatonia
• Peripartum onset
• Seasonal pattern

Question 4

Bipolar depression vs Unipolar depression

Answer 4

Diagnostic criteria for bipolar depression and unipolar depression are similar and there are no pathognmomic signs that can reliably distinguish.

Symptoms more common in bipolar depression include

1. Psychotic features
2. Atypical depressive features e.g. hypersomnia, hyperphagia
3. Earlier first lifetime episode
4. Prevalence of comorbid anxiety, susbtance use or personality disorders
5. Social functioning poorer
6. Subthreshold manic/hypomanic symptoms (i.e. unipolar depression with mixed features)
7. Family history of bipolar
8. Multiple recurrences of major depression
9. Poor response to anti-depressants

Question 5

Substance use disorder

Answer 5

At least 2 of the following within a 12 month period

1. Tolerance
2. Withdrawal
3. No control: substance is taken in larger amounts than intended
4. Need to cut down: persistent desire or unsuccessful efforts to cut down or control use of the substance
5. Loses time: spent on procuring, recovering or using
6. Craves
7. Failed roles: at work/school or home due to effects of drugs
8. Helpless: continued use despite suffering from its effects
9. Trades off: socio-occupaitonal/recreational activities are givenup or reduced due to its use

Severity can be specificied by number of positive symptoms

• 2-3 symptoms: mild
• 4-5 symptoms: moderate
• 6 or more: severe