MOOD + PSYCHOTIC DISORDERS

Olivia Wu, updated 10/2018 from First Aid 2018, DGSOM lectures 2018, DSM V (https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596)

Mania/Bipolar Disorder Depression

Elevated ("feeling good") and/or irritable, nonreactive mood + DIG FAST * Depressed, nonreactive mood ("feeling down") + SIG E CAPS
1. Distractibility (response to external stimuli) 1. Sleep disturbance
2. Impulsivity/Indiscretion
2. *Interest loss (anhedonia)
3. Grandiosity
3. Guilt, feelings of worthlessness, hopelessness
4. Flight of ideas (internal) 4. Energy loss and fatigue, independent of amount of sleep
5. Activity (goal-directed) / Psychomotor Agitation 5. Concentration problems
6. Sleep (decreased need)S 6. Appetite/weight changes
7. Talkativeness/pressured speech 7. Psychomotor retardation or agitation
8. Suicidal ideation
Manic: ≥ 3 sx for > 1 wk *Always ask about depressed mood and interest loss - highly specific
If mood is only irritable (not elevated), then ≥ 4
Mood disturbance severe enough to impact social/occupational functioning or necessitate hospitalization
"1 fun week," though average episode 3-6 months MAJOR/UNIPOLAR DEPRESSIVE DYSTHYMIA DOUBLE DEPRESSION
DISORDER (MDD)
Hypomanic: ≥ 3 sx for ≥ 4 days dysthymia + acute MDD episodes
• ≥ 5 sx for ≥ 2 wks • 5 > sx ≥ 2 for ≥ 2 years
If mood is only irritable (not elevated), then ≥ 4
Mood disturbance is less severe, NOT significantly impacting social/occupational functioning • At least 1 sx is depressed mood or • No more than 2 mo. w/o sx
loss of interest/pleasure
• Other sx can include anxiety, aka PERSISTENT
BIPOLAR I BIPOLAR II CYCLOTHYMIA somatic DEPRESSIVE DISORDER
• ≥ 1 manic episode • Hypomanic + major depressive • Hypomanic + mild depressive • "2 blue weeks," though average
episode fluctuations ≥ 2 years episodes 6-12 mo.
• +/- hypomanic or major depressive
episode, separated by any length of • NO manic episode • Criteria for other major mood • Independent of other medical
disorders not met (you don't have condition or substance use
time
"double bipolar" like you do "double
depression") SEASONAL PATTERN is a subtype
MIXED STATE is a subtype w/ manic
w/ ≥ 2 major depressive episodes in
symptoms + depressive mood AT
a seasonal pattern over ≥2 years;
THE SAME TIME. Increased suicide
often with atypical features
risk.

Other depressive subtypes

Schizophrenic spectrum • MELANCHOLIC/SEVERE: extreme neuroveg. sx
+ Positive symptoms (Psychosis) • POSPARTUM: similar to MDD
Distorted perception of reality thought to be caused by increased DA action. • PSYCHOTIC: severe depression with psychotic sx
1. Delusions - false beliefs persisting despite facts • CATATONIC
2. Hallucinations (often auditory) - perceptions in the absence of stimuli • SUBSTANCE-INDUCED
3. Disorganized speech - incoherent ("word salad"), tangential, or derailed ("loose associations" b/w sentences/phrases) • SECONDARY: assoc. w/ another medical condition
4. Disorganized/catatonic behavior • ATYPICAL: Mood reactivity, "reversed" vegetative symptoms (hypersomnia, hyperphagia leading to weight gain),
- Negative symptoms leaden paralysis, long-standing interpersonal rejection sensitivity
1. Affective flattening (less eye contact, spontaneity, emotion), avolition, anhedonia, asociality, alogia
• ADJUSTMENT DISORDER: < 5 sx, acute, normal response to life stress

BRIEF PSYCHOTIC SCHIZOPHRENIFORM SCHIZOPHRENIA SCHIZOAFFECTIVE MOOD DISORDER W/

DISORDER DISORDER
≥ 1 sx for < 1 mo. ≥ 2 sx for 1-6 mo. • ≥ 2 sx for > 6 mo.
• At least 1 sx must be from #
1-3
• Psychotic sx only - NO
mood episodes
DISORDER
• Schizophrenia + major
mood disorder (major
depressive or bipolar)
SEPARATELY
• > 2 wks. psychotic sx w/o
major mood episode
Schizoaffective disorder, bipolar type
PSYCHOTIC FEATURES
• Psychotic symptoms +
major mood disorder AT
THE SAME TIME
• We do not classify
"dysthymia/cyclothymia
with psychotic features"
Bipolar I w/ psychotic features
Epidemiology
• Bipolar Disorders/Manic Depression: females = males
• Major/Unipolar Depressive Disorder: females > males, 20s-30s
• Schizophrenia: males > females, presents in late adolescent or early adulthood (15-25 for men, 25-35 for females)
Treatment
• Bipolar Disorder/Manic Depression: lifelong combo for both acute treatment and long-term maintenance
1. Mood stabilizer: Li+, valproic acid, carbamazepine, lamotrigine
§ Li+, valproic acid, carbamazepine effective for manic episodes
§ Li+, lamotrigine effective for depressive episodes
2. Atypical antipyschotic
§ Most are effective for manic episodes
§ Quetiapine, lurasidone, olanzapine effective for depressive episodes
• Major/Unipolar Depressive Disorders: CBT + SSRIs are first line, otherwise depends on side effects and tolerance.
Note that they take several weeks to take effect, so adherence is an issue. ECT for treatment-resistant patients. Light
box therapy for seasonal pattern.
• Atypical depression: MAOIs are most effective
• Schizophrenia: atypical antipsychotics
○ Clozapine is best bet for unresponsive patients
○ "Responsivity" = at least 20% reduction in symptoms
○ Negative symptoms often persist

Schizoaffective disorder, MDD type MDD w/ psychotic features