Bipolar Disorders Psychiatry 2

Dr. Besa
First Shifting
24 July 2008

BIPOLAR DISORDER – both manic and depressive • Glutamate & Glycine – neurotoxic effects;
episodes or manic episodes glutamate + hypercortisolemia = depression
alone
HYPOMANIA – manic symptoms that does not Hormones
meet DSM-IV-TR • TSH - depression
CYCLOTHYMIA – less severe form of bipolar
• GH – inh by somatostatin and CRH;
disorder
↓somatostatin in depression, ↑ in mania
DYSTHYMIA – less severe form of major depression
• Prolactin – stim by serotonin, inh by dopamine
History Sleep: depression
• Hippocrates – mania and melancholia
• Jules Falret – folie circulaire: alternating moods ↓lymphocytes: depression
of depression and mania
Brain (in Mania): Increased frequency of abnormal
• Karl Kahlbaum – cyclothymia
hyperintensities in subcortical region
• Emil Kraeplin – bipolar I disorder and
involutional melancholia GENETIC FACTORS
• Family: Depression
Epidemiology • Adoption: 3x increase in bipolar
• Lifetime prevalence: 2.4% • Twins: 50-70%; monozygotic 70-90%, dizygotic
• Bipolar I –equal men & women 16-35%
• Manic episodes • Linkage: chr 18q and 22q; 18 fr mother, 21q in
◦ More common in men schiz & bipolar, 22q (BCR gene) in neuron
◦ Women have higher rate for rapid cyclers growth & axonal guidance
• Age: 5-6 years old, to 50 mean age=30
• Marital status: divorce and single PSYCHOSOCIAL
• Socioeconomic: upper socioeconomic groups
• Life events & envtl stess: depression
• Personality factors: OCD, histrionic &
Comorbidity borderline in depression; dysthymic and
• Substance abuse (self medication with alcohol) cyclothymic d/o in MDD or bipolar I d/o
• Anxiety disorder: worsen prognosis and increase • Psychodynamic Factors
risk of suicide ◦ defense against underlying depression
◦ Abraham: inability to tolerate development
Etiology tragedy; result from tyrannical superego →
intolerable self-critism → euphoric self-
BIOLOGICAL FACTORS satisfaction
- Monoaminergic systems ◦ Lewin: ego overwhelmed by pleasurable
impulses
Biogenic amines
◦ Klein: defensive reaction to depression
• NE & serotonin - depression
• Dopamine - reduced in depression, increased in Diagnosis
mania
- Reduce dopamine: reserpine, BIPOLAR I DISORDER
Parkinson’s dse - Bipolar II: depressive and hypomanic
- Increased dopamine: tyrosine, - Manic ppt by antidepressant tx ≠ bipolar I
amphetamine, buproprion - Criteria for Manic:
(Wellbutrin) • Persistently elevated, expansive and
Other NTs irritable mood, one week
• ACh – agonists produce lethargy, anergia, • 3 or more of the following symptoms:
psychomotor retardation, exacerbate sx of ◦ Grandiosity
depression, reduce sx of mania ◦ Decrease need for sleep
• GABA – reduction in depression ◦ More talkative
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 PSYCH2
BIPOLAR DISORDERS

◦ Flight of ideas
◦ Distractibility
◦ Increase in goal = directed activity or
psychomotor agitation
◦ Pleasurable activity with painful
consequences
• Do not meet criteria for mixed episodes
• SEVERE to cause marked impairment or to
necessitate hospitalization
• Not due to substance abuse, general
medical condition (GMC)

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 PSYCH2
BIPOLAR DISORDERS

Bipolar I disorder, single manic episode With rapid cycling.

- Manic Episode – 1st manic episode

Table 15.1-14 • Bipolar I disorder, most recent episode

A. Presence of only one manic episode and no past
major depressive episodes.
Note: Recurrence is defined as either a change in
polarity from depression or an interval of at least 2
months w/o manic symptoms.
B. The manic episode is not better accounted for by
schizoaffective disorder and is not superimposed
on schizophrenia, schizophreniform disorder,
delusional disorder, or psychotic disorder not
otherwise specified.
Specify if :
Mixed: If symptoms meet criteria for a mixed episode
if the full criteria are currently met for a manic, mixed,
or major depressive episode, specify its current clinical
status and/or features:
Mild, moderate, severe w/o psychotic
features/severe with psychotic features
With catatonic features, with postpartum onset
hypomanic (Table 15.1-16)
A. Currently (or most recently) in a hypomanic
episode.
B. There has previously been at least one manic
episode or mixed episode.
C. The mood symptoms cause clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
D. The mood episode in criteria A and B are not
better accounted for by schizoaffective disorder
and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder, or
psychotic disorder not otherwise specified.
Specify if:
Longitudinal course specifies (with and w/o
interepisode recovery)
With seasonal pattern (applies only to the
pattern of major depressive episodes)
With rapid cycling.

If the full criteria are not currently met for a manic,

mixed or major depressive episode, specify the • Bipolar I disorder, most recent episode
current clinical status of bipolar I disorder or features
depressed (Table 15.1-17)
of the most recent episode:
A. Currently (or most recently) in a major depressive
In partial remission, in full remission
episode.
With catatonic features
B. There has previously been at least one manic
With postpartum onset
episode or mixed episode.
C. The mood episode in criteria A and B are not
better accounted for by schizoaffective disorder
Bipolar I disorder, recurrent
and are not superimposed on schizophrenia,
- separated by at least 2 months without schizophreniform disorder, delusional disorder, or
significant symptoms of mania or hypomania psychotic disorder not otherwise specified.
If the full criteria are currently met for major
• Bipolar I disorder, most recent episode manic depressive episode, specify its current clinical status
(Table 15.1-15) and /or features:
A. Currently ( or most recently) in manic episode. Mild, moderate, sever w/o psychotic features,
B. There has previously been at least one major sever w/ psychotic features,
depressive episode, manic episode, or mixed Chronic
episode. With catatonic features
C. The mood episode in criteria A and B are not With melancholic features
better accounted for by schizoaffective disorder With atypical features
and are not superimposed on schizophrenia, With postpartum onset
schizophreniform disorder, delusional disorder, or
psychotic disorder not otherwise specified. If the full criteria are not currently met for a major
depressive episode, specify the current clinical status
If the full criteria are currently met for a manic of bipolar I disorder and/or features of the most recent
episode, specify its current clinical status and/or major depressive episode:
features: In partial remission, in full remission
Mild, moderate, severe w/o psychotic Chronic
features/severe with psychotic features With catatonic features
With catatonic features, with postpartum onset With melancholic features
With atypical features
If the full criteria are not currently met for a manic With postpartum onset
episode, specify the current clinical status of bipolar I
disorder and/or features of the most recent manic Specify if:
episode: Longitudinal course specifies (with and w/o
interepisode recovery)
In partial remission, in full remission With seasonal pattern (applies only to the
With catatonic features pattern of major depressive episodes)
With postpartum onset With rapid cycling
Specify if:
Longitudinal course specifies (with and w/o
interepisode recovery) • Bipolar I disorder, most recent episode mixed
With seasonal pattern (applies only to the (Table 15.1-18)
pattern of major depressive episodes)

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 PSYCH2
BIPOLAR DISORDERS
A. Currently (or most recently) in a major depressive
episode.
B. There has previously been at least one major
depressive episode, manic episodes or mixed
episode.
C. The mood episode in criteria A and B are not
better accounted for by schizoaffective disorder
and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder, or
psychotic disorder not otherwise specified.
If the full criteria are currently met for mixed episode,
specify its current clinical status and /or features:
Mild, moderate, sever w/o psychotic features,
sever w/ psychotic features,
With catatonic features
With postpartum onset
If the full criteria are not currently met for a mixed
episode, specify the current clinical status of bipolar I
disorder and/or features of the most recent mixed
episode:
In partial remission, in full remission
With catatonic features
With postpartum onset
Specify if:
Longitudinal course specifies (with and w/o
interepisode recovery)
With seasonal pattern (applies only to the
pattern of major depressive episodes)
With rapid cycling.
• Bipolar I disorder, most recent episode
unspecified (Table 15.1-19)
A. Criteria, except for duration, are currently ( or
most recently) met for a manic, a hypomanic, a
mixed, or major depressive episode.
B. There has previously been at least one manic
episode or mixed episode.
C. The mood symptoms cause clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
D. The mood symptoms in criteria A and B are not
better accounted for by schizoaffective disorder
and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder, or
psychotic disorder not otherwise specified.
E. The mood symptoms in criteria A and B are not
due to the direct physiological effects of a
substance( e.g. a drug of abuse, medication, or
other treatment) or general medical condition(
e.g. hyperthyroidism).
Specify if:
Longitudinal course specifies (with and w/o
interepisode recovery)
With seasonal pattern (applies only to the
pattern of major depressive episodes)
With rapid cycling.
Criteria for Severity/Psychotic/Remission
Specifiers for Current (or Most Recent MANIC
episode (Table 15.1-10)
Note: Code in fifth digit. Mild, moderate, severe w/o
psychotic features, severe w/psychotic features can be
applied only if the criteria are currently met for manic
episode. In partial remission and in full remission can be
applied to a manic episode in bipolar I disorder only if it is
the most recent type of mood episode.
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Mild: Minimum symptom criteria are met for a manic
episode.
Moderate: Extreme increase in activity or impairment in
judgment.
Severe without psychotic features: Almost continual
supervision required to prevent physical harm to self and
other.
Severe with psychotic features: Delusion or
hallucination. If possible, specify whether the psychotic
features are mood- congruent:
Mood- congruent psychotic features: delusion or
hallucination whose content is entirely consistent with
the typical manic themes or inflated worth, power,
knowledge, identity, or special relationship to deity or
famous person.
Mood- incongruent psychotic features: Delusion or
hallucination whose content does not consistent with
the typical manic themes or inflated worth, power,
knowledge, identity, or special relationship to deity or
famous person. Included are such symptoms as
persecutory delusion (not directly related to grandiose
ideas or themes), thought insertion, and delusions of
being controlled.
In partial remission: Symptoms of manic episode are
present but full are not met, or there is a period w/o any
significant symptoms of manic episode lasting 2 months
following the end of manic episode.
In full remission: During the past 2 months no significant
signs or symptoms of disturbance were present.
Hypomanic
- Persistently elevated, expansive and irritable
mood, lasting at least 4 days
- 3 or more of same symptoms
- Uncharacteristic of the person
- Change in functioning observable by others
- NOT SEVERE to cause marked impairment or
to necessitate hospitalization
- Not due to substance abuse, GMC
Mixed Episode
- Met for both manic and depress episodes
everyday for 1 week
- Severe to cause impairment
- Not due to substance, GMC
Criteria for Severity/Psychotic/Remission
Specifiers for Current (or Most Recent MIXED
episode Table 15.1-11
Note: Code in fifth digit. Mild, moderate, severe w/o
psychotic features, severe w/psychotic features can be
applied only if the criteria are currently met for mixed
episode. In partial remission and in full remission can be
applied to a mixed episode in bipolar I disorder only if it is
the most recent type of mood episode.
Mild: No more than minimum symptom criteria are met
for a manic episode and major depressive episode.
Moderate: Symptoms or functional impairment between
mild and severe.
Severe without psychotic features: Almost continual
supervision required to prevent physical harm to self and
other.
Severe with psychotic features: Delusion or
hallucination. If possible, specify whether the psychotic
features are mood- congruent or mood- incongruent:
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 PSYCH2
BIPOLAR DISORDERS
Mood- congruent psychotic features: delusion or
hallucination whose content is entirely consistent with
the typical manic themes or depressive themes.
Mood- incongruent psychotic features: Delusion or
hallucination whose content does not involved with
the typical manic theme or depressive theme.
Included are such symptoms as persecutory delusion
(not directly related to grandiose ideas or themes),
thought insertion, and delusions of being controlled.
In partial remission: Symptoms of mixed episode are
present but full are not met, or there is a period w/o any
significant symptoms of mixed episode lasting 2 months
following the end of mixed episode.
In full remission: During the past 2 months no significant
signs or symptoms of disturbance were present.
BIPOLAR II DISORDER
- One or more depressive episode
- At least one hypomanic episode
- Never had manic or mixed episode
- Not due to schizophrenia
- Significant impairment
A. Presence (or history) of one or more major depressive
episode.
B. Presence (or history) of the least one hypomanic
episode.
C. There has been a manic episode or mixed episode.
D. The mood symptoms in criteria A and B are not better
accounted for by schizoaffective disorder and are not
superimposed on schizophrenia, schizophreniform
disorder, delusional disorder, or psychotic disorder not
otherwise specified.
E. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
Specify current or most recent episode:
Hypomanic: if currently ( or most recently ) in a
hypomanic episode.
Depressed: if currently ( or most recently ) in a major
depressive episode.
If the full criteria are currently met for major depressive
episode, specify its current clinical status or features:
Mild, moderate, severe w/o psychotic features
severe w/psychotic features. Note: Fifth-digit codes
cannot be used here because the code for bipolar II
disorder already uses the fifth digit.
Chronic
With catatonics features
With melancholic features
With atypical features
With postpartum onset
If the full criteria are not currently met for a hypomanic or
major depressive episode, specify its current clinical status
or features of the bipolar II disorder and/or features of the
most recent major depressive episode ( only if it is the
most recent type of mood episode):
In partial remission, In full remission: Note : Fifth-
digit codes cannot be used here because the code for
bipolar II disorder already uses the fifth digit.
Chronic
With catatonics features
With melancholic features
With atypical features
With postpartum onset
Specify if:
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Longitudinal course specifies (with and w/o
interepisode recovery)
With seasonal pattern (applies only to the pattern
of major depressive episodes)
With rapid cycling.
Recurrent Course:
• With rapid cycling: BID, BIID
• With seasonal pattern: BID, BIID, MDD
• With or without full interepisode recovery: BID,
BIID, MDD
• With postpartum onset: BID, BIID, MDD, BPD
(brief psychotic disorder)
• Rapid cycling: BID, BIID
◦ Female with depressive and hypomanic
episodes
◦ Stress or drug treatment
◦ 4 episodes in 1 year
SPECIFIERS (MOST RECENT EPISODE )
With Psychotic Features
- Poor prognostic indicator
- Bipolar I: families of probands with psychotic
depression
- Mood congruent: “I deserve to be punished
bec I am so bad”
- Mood incongruent: may have schizoaffective
disorder or schizophrenia
- Poor prognosis: long duration of episodes,
temporal dissociation, poor premorbid history
- Tx: antipsychotic drugs + antidepressants or
mood stabilizers
With Melancholic Features
- Severe anhedonia, early morning awakening,
weight loss, and profound feelings of guilt
- Assoc with changes in ANS and endocrine fcns
- “endogenous depression”: depression in the
absence of external life stressors
Specify if:
With melancholic features: (can be applied to the
current or most recent major depressive episode in
major depressive disorder and to a major depressive
episode in bipolar I or bipolar II disorder only if it is the
most recent type of mood episode).
A. Either of the following, occurring during the most
severe period of the current episode:
(1) Loss of pleasure in all, or almost all, activities.
(2) Lack of reactivity to usually pleasurable stimuli
(does not feel much better, even temporarily,
when something good happens).
B. Three (or more) of the following:
(1) Distinct quality of depressed mood (i.e., the
depressed mood is experienced after the death
of loved one)
(2) Depression regularly worse in the morning
(3) Early morning awakening (at least 2 hours before
usual time of awakening)
(4) Marked psychomotor retardation or agitation
(5) Significant anorexia or weight loss
(6) Excessive or inappropriate guilt
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 PSYCH2
BIPOLAR DISORDERS
With Atypical Features
- Reversed vegetative symptoms; sx pattern:
hysteroid dysphoria
- Younger onset of age
- More severe psychomotor slowing
- More frequent coexisting diagnoses of panic
disorder, substance abuse or dependence, and
somatisation disorder
- Long term cause
Specify if:
With Atypical Features (can be applied when these
features predominate during the most recent 2 weeks of
a current major depressive episode in major depressive
disorder or in bipolar I or bipolar II disorder when a
current major depressive episode is the most recent
type of mood episode,or when these features
predominated during the most recent 2 years of
dysthymic disorder: if the major depressive episode is
not current, it applies if the features predominates
during 2 weeks period)
A. Mood activity ( i.e., mood brightens in response to
actual or potential positive events)
B. Two (or more) of the following features:
(1) Significant weight gain or increase in appetite
(2) Hypersomnia
(3) Leaden paralysis ( i.e., heavy, leaden, feelings
arms or legs )
(4) Long- standing pattern of interpersonal rejection
sensitivity ( not limited to episodes mood
disturbance) that results in significant social or
occupational impairment.
C. Criteria are not met for with melancholic features or
with catatonic features during the same episode.
With Catatonic Features
- Most commonly schizophrenia and mood
disorder
- Prognostic and tx significance
Specify if:
With Catatonic Features (can be applied to the
current or most recent major depressive episode, manic
episode, or mixed episode in major depressive disorder,
bipolar I or bipolar II disorder).
The clinical picture is dominated by at least 2 of the
following:
(1) Motoric immobility as evidence by catalepsy
(including waxy flexibility) or stupor.
(2) Excessive motor activity (that is apparently
purposeless and not influenced by external stimuli)
(3) Extreme negativism (an apparently motiveless
resistance to all instruction or maintenance of a
rigid posture against attempts to be moved) or
mutism
(4) Peculiarities of voluntary movement as evidenced
by posturing (voluntary assumption of
inappropriate or bizarre posture), stereotyped
movements, prominent mannerism, or prominent
primacing
(5) Echolalia or echopraxia
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Postpartum Onset
Specify if:
Postpartum Onset (can be applied to the current or
most recent major depressive, manic, or mixed episode
in major depressive disorder, bipolar I disorder, bipolar II
disorder; or to brief psychotic disorder)
Onset of episode within 4 weeks postpartum.
Chronic
Specify if:
Chronic (can be applied to the current or most recent
major depressive episode in major depressive disorder
and to a major depressive episode in bipolar I or II
disorder only if it is the most recent type of mood
episode)
Full criteria for major depressive episode have been
met continuously for at least the past 2 years.
DESCRIBING COURSE FOR RECURRENT EPISODES
Rapid Cycling
- Female
- Depresseive and hypomanic episodes
- Pathogenesis: stress or drug treatment
- At least 4 episodes within 12 month period
Specify if:
Rapid Cycling (can be applied to bipolar I disorder or
bipolar II disorder)
At least four episode of a mood disturbance in the previous
12 months that meet the criteria for major depressive,
manic, mixed, or hypomanic episode.
Note: Episode are demarcated either by partial or full
remission for at least 2 months or switch to an episode of
opposite polarity (e.g., major depressive episode to manic
episode).
Seasonal Pattern
- Most commonly winter
- Seasonal affective disorder
- 2 evidence
1. Likely to respond to light therapy
2. Decreased metabolic activity in the orbital
frontal cortex and left inferior parietal lobe
Specify if:
Seasonal Pattern (can be applied to the pattern of major
depressive episode in bipolar I disorder, bipolar II disorder,
or major depressive disorder, recurrent).
A. There has been a regular temporal relationship
between the onset of major depressive episode in
bipolar I or II disorder or major depressive disorder,
recurrent and a particular time of the year (e.g.,
regular appearance of the major episode in the fall or
winter).
NOTE: do not include cases in which there is an
obvious effect of seasonal-related psychosocial
stressor (e.g, regularly being unemployed every
winter).
B. Full remission (or a change from depression to mania
or hypomania) also occur at a characteristic time of
the year (e.g., depression disappears in the spring).
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BIPOLAR DISORDERS

C. In the last 2 years, two major depressive episode • Other Substance-Related Disorders: ppt an
have occurred that demonstrate the temporal episode of illness or patient’s attempt to treat
seasonal relationship defined in criteria A and B, and
no non seasonal major depressive episode have
their own illnesses; cocaine & amphetamine
occurred during the same period • Medical Conditions: older persons; medical
D. Seasonal major depressive major depressive episodes condition/drugs taking = depression; cancer
(as describe above) substantially outnumber the non-
seasonal major depressive episodes that may have
occurred over individual’s lifetime.
MSE
Gen description: Euphoric, very loud voice
Longitudinal Course Specifiers Mood, affect,
Specify if (can be applied to recurrent major depressive feeling: Elevated mood
disorder or bipolar I or II disorder): Loud voice, flight of ideas, Not
With full interepisode recovery: in full remission is Speech:
connected with each other
attained between two most recent mood episodes Perceptual
Without full interepisode recovery: if full remission is disturbance: Hallucination, delusion, grandiose
not attained between the two most recent mood episode. Preoccupied with sexual,
Thought:
political,religious, persecutory ideas
NON-DSM-IV-TR TYPES Sensorium and Intact memory, oriented to time,
• Endogenous-reactive continuum
memory: place and person
- Endogenous depressions are biological;
Impulse control: Poor
Reactive depressions are psychological Judgement and Very poor, no insight about their
- Endogenous depression: similar to MDD w/
insight: illness
psychotic features or melancholic features
Reliability: Notoriously unreliable
- Reactive depression: initial insomnia,
anxiety, emotional lability, multiple somatic Course and Prognosis
complaints
BID
• Primary Depression: Mood disorders caused by • Graphing the course patient’s disorder
GMC • Starts with depression (usually)
• Secondary Depression: substance-induced mood • Recurring disorder
disorder • Manic episodes have rapid onset, untreated
• Double Depression: MDD superimposed on episodes lasts 3 months
dysthymic d/o • Time between episodes decreases
• Depressive equivalent: forme fruste of • 4 or more episodes a year  rapid cycler
depressive episode • Poor prognosis: poor occupational status,
alcohol dependence, psychotic features, male
Clinical Features gender
MANIC EPISODES
BIID
• Hallmark: Elevated/euphoric, expansive,
• Diagnosis is stable
irritable mood
• Chronic disease that needs loner term
• Excessive alcohol intake to self-medicate
treatment strategies
• Disinhibited nature
• Act impulsively with sense of conviction and
purpose Treatment
• Preoccupied with religious, political, financial, ACUTE MANIC
sexual, persecutory ideas • Mood stabilizers:
• In adolescents: often misdiagnosed as antisocial
◦ Lithium = best; 900-1800 mg/day
personality disorder or schizophrenia
◦ Valproate = 750-2000 mg/day
◦ Carbamazepine = 800-1800 mg/day
BIPOLAR II DISORDER ◦ Clonazepam
• MDD + hypomanic • Atypical and typical antipsychotic (alone)
• More marital disruption ◦ Risperdal
• Onset at an earlier age ◦ Abilify

C OEXISTING DISORDERS ACUTE BIPOLAR DEPRESSION

• Anxiety: mixed anxiety-depressive disorder • Anti depressants induce cycling, mania,
• Alcohol Dependence: women hypomania
• Antidepressants + mood stabilizer
• Lamotrigine
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BIPOLAR DISORDERS

• Symptomatically a form of BIID

Maintainance: Lithium, valproate = get • Chronic, fluctuating disturbances with many
therapeutic level periods of hypomania and depression
• Positive history for BID

OTHER MOOD DISTURBANCES

DYSTHYMIA DEPRESSIVE DISORDER NOS
• Minor Depressive Disorder
• Less severe depression ◦ at least 2 but less than 5 symptoms
• Patient complains that they are always • Recurrent Brief Depressive Disorder
depressed ◦ less than 2 weeks
• Usually early onset ◦ at least once a month for 12 months
• 5-6% of general population ◦ not associated with menstrual cycle
• No gender difference • Premenstrual Dysphoric Disorder
• Coexists with anxiety disorder, substance ◦ late luteal phase dysphoric disorder
abuse, borderline psychotic disorder ◦ mood / behavior / physical symptoms
• Psychosocial Factors: results from personality ◦ occurs at specific time in menstrual cycle
and ego development and culminates in and resolves between menstrual cycle
difficulty adapting to adolescence and early • Post Psychotic Depressive Disorder
adulthood ◦ Major Depressive Disorder during residual
phase
C RITERIA ◦ vulnerability to mental illness which lowers
• Depressed for most of the day for at least 2 self-esteem
years • Bipolar Disorder NOS
• 2 or more of the following: ◦ Mixed Anxiety Depressive Disorder
◦ Poor appetite/overeating ◦ Atypical Depression
◦ Insomnia/hyperinsomnia
◦ Low energy/fatigue SECONDARY MOOD DISORDER
◦ Low self-esteem • Mood disorder due to GMC
◦ Poor concentration/difficulty making • Substance induced mood disorder
decisions
◦ Feelings of hopelessness
• Has never been without the symptoms for > 2
Classmates.. ung treatment, dysthymia & cyclothymia at others, paread nlng sa book..
months
senxa na kng dq na nalagay ung tx ung krugtong ng limpak2 na tables (sna salapi
• No major depression/mania/hypomania/mixed nlng!).. ndi na kc un diniscuss, e parang mas impt ung mga gamot, kc un din nmn ang
episodes tnatanong sa exam.. ska ung iba, sa MDD rin... (lulusot pa o!).. tnx2.. God bless! –malta
• Not due to psychotic disorder
• Not due to substance abuse or GMC Tnong: paano kbisaduhin ang buong MIMS o PPDr? Sadya bang lakas chamba lng ang
medthera? Kung may swerte man, possible ba na kng lhat ay naitama ay considered na
C LINICAL FEATURES : “batugan” “luck”? hehehe..  bangag!
• Habitual gloom, brooding, lack of joy in life,
preoccupation with inadequacy Lunes na nmn po.. ansaya! surg path → medthera → pedia (w/dr.dr!).. life!
• Long-standing, fluctuating, low-grade
depression experienced as part of habitual self

TREATMENT
• Pharmacotherapy
• Psychotherapy
◦ New ways of thinking and behaving to
replace negative attitude
◦ Allowing personal behavior goals to
increase activity, provide pleasant
experiences, ways to relax
◦ Ways of coping with stress

CYCLOTHYMIA
• Lesser BIID

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