Chapter 17 Manic Disorder

Criteria for manic episode according to DSM-IV A.A distinct period of abnormally and persistently elevated,expansive,or irritable mood, lasting ≥1 week (or any duration if hospitalization is necessary) B. During the period of mood disturbance, ≥3 of the following symptoms have persisted and have been present to a significant degree. # inflated self esteem or grandiosity # decreased need for help # more talkative than usual or pressure to keep talking # flight of ideas or subjective experience that thought are reacting # distractibilty (e.g. attention too easily drawn to unimportant or irrelevant external stimuli) # increase in goal directed activity (either socialy at work or school, or sexually) or psychomotor agitation # excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained

shopping sprees sexual indiscretions, or foolish business investments ) C. the symptoms do not meet criteria for a mixed episode D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessiate hospitalization to prevent harm to self or others or there are psychotic features E. The symptoms are not due to the direct physiological effects of a substance (e.g. drug of abuse, medication, or other treatment) or a GMC (e.g. hyperthyroidism) Note: manic like episodes that are clearly caused by somatic antidepressant treatment ( e.g. medication, ECT therapy, light therapy) should not count toward a diagnosis of Bipolar I disorder

Mixed episode 1.Criterion met for both manic episode and MDE nearly every day for 1 week 2. criterion D and E of manic episodes are met Hypomanic episodes 1.Criterion A of a manic episode is met, but duration is ≥4 days. 2.Criterion B and E manic episodes are met 3.Episode associated with an uncharacteristic decline in functioning that is observable by others 4.Change in function is not severe enough to cause marked impairment in social or occupational functioning or to necessiate hospitalization. 5.Absence of psychotic features.

How a manic patient commonly presents 1.Appropriate but elevated, euphoric, irritable, labile mood ( singing, rhyming and makes you laugh) 2.Talking excessively and big, making a lot of inappropriate plans (due to grandiosy about wealth, worth, knowledge or power) 3.Increased psychomotor activity (restless), increased sociability 4.Spending speers ( excessive buying or distribution of money, foolish business investments, prone to economical loss) 5.Distractible, inattentive 6.Increased production of thoughts, jumping from one thought to another, difficult to interrupt (pressure of speech) 7.Decreased need for sleep and appetite 8.Inflated self esteem, increased libido 9.Maintains personal hygiene but inappropriately overdecorate 10.May be suspicious (that others are trying to take away his wealth 11.Does not accept that he is ill (lack insight) 12.Sudden onset, may remit or change into depression

Epidemiology of mood disorder 1.prevalence: male2.9%, female 5% 2.Lifetime prevalence: peak prevalence age yrs (M:F = 1:2) 3.Mean age of onset is 30 years Etiology 1.Biological # genetic: 65-75% MZ twins; 14-19% DZ twins # neurotransmitter dysfunction: decreased activity of 5HT,NE and DA at the level of the synapse, changes in GABA and glutamate, changes in brain circuitry # neuroendocrine dysfunction: increased production of corticotropin causing excessive HPA axis activity #neuroanatomy : smaller frontal lobes and hippocampal volume ; increased ventricle sizes

# neurupsychologic: decreased REM latency and slow wave sleep; increased REM length # secondary to GMC 2. Psychosocial # psychodynamic (low self esteem) # cognitive (e.g. negative thinking) # environmental factors (e.g. job loss, bereavement, history of abuse, early life adversity) #co-morbid psychiatric diagnosis: (e.g. anxiety, substance abuse, developmental disability, dementia, eating disorder)

Risk factors for mood disorders 1.sex: female > male 2.Age: onset between yrs of age 3.Family history: depression, alcohol abuse, sociopathy 4.Childhood experiences: loss of parent before age 11, negative home environment (abuse, neglect) 5.Personality: insecure, dependent, obsessional 6.Recent stressors: illness, financial, legal 7.Postpartum: <6 months 8.Lack of intimate, confiding relationships or social isolation

Treatment 1.biological: antidepressants, lithium, antipsychotics, anxiolytics, ECT, light therapy 2.Psychological # individual therapy: psychodynamic, interpersonal, CBT # family therapy # group therapy 3. social: vocational rehabilitation, social skills training 4. experimental: deep brain stimulation, transcranial magnetic stimulation, vegal nerve stimulation 5. Studies suggests CBT with pharmacotherapy results in better outcomes

Prognosis One year after diagnosis of a MDR without treatment ; 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full MDE, 20% continue to have some symptoms that no longer meet criteria for a MDE, 40% have no mood disorder

Treatment  Anti psychotic  Mood stabilizer  Sedative  Psychotherapy

The End