Chapter 17Manic Disorder

Criteria for manic episode according to DSM-IVA. 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 episodeD. 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 episode1. Criterion met for both manic episode and MDE nearly every day for 1

week2. criterion D and E of manic episodes are metHypomanic episodes3. Criterion A of a manic episode is met, but duration is ≥4 days.4. Criterion B and E manic episodes are met5. Episode associated with an uncharacteristic decline in functioning

that is observable by others6. Change in function is not severe enough to cause marked

impairment in social or occupational functioning or to necessiate hospitalization.

7. Absence of psychotic features.

How a manic patient commonly presents1. 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 sociability4. Spending speers ( excessive buying or distribution of money, foolish

business investments, prone to economical loss)5. Distractible, inattentive6. Increased production of thoughts, jumping from one thought to

another, difficult to interrupt (pressure of speech)7. Decreased need for sleep and appetite8. Inflated self esteem, increased libido9. Maintains personal hygiene but inappropriately overdecorate10.May be suspicious (that others are trying to take away his wealth11.Does not accept that he is ill (lack insight)12.Sudden onset, may remit or change into depression

Epidemiology of mood disorder1. prevalence: male2.9%, female 5%2. Lifetime prevalence: peak prevalence age 15-25 yrs (M:F = 1:2)3. Mean age of onset is 30 yearsEtiology4. 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 GMC2. 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 disorders1. sex: female > male2. Age: onset between 25-30 yrs of age3. Family history: depression, alcohol abuse, sociopathy4. Childhood experiences: loss of parent before age 11, negative home

environment (abuse, neglect)5. Personality: insecure, dependent, obsessional6. Recent stressors: illness, financial, legal7. Postpartum: <6 months8. Lack of intimate, confiding relationships or social isolation

Treatment1. biological: antidepressants, lithium, antipsychotics, anxiolytics, ECT,

light therapy2. Psychological # individual therapy: psychodynamic, interpersonal, CBT # family therapy # group therapy3. social: vocational rehabilitation, social skills training4. experimental: deep brain stimulation, transcranial magnetic stimulation,

vegal nerve stimulation5. Studies suggests CBT with pharmacotherapy results in better outcomes

PrognosisOne 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