Depression and Bipolar

Disorder (kaplan &

sadock)
Resume
Dr liza
 Mood is a pervasive and sustained feeling
tone that is experienced internally and that
influences a person's behavior and perception
of the world.
 Affect is the external expression of mood.

Mood can be:

 normal,
 elevated,
 or depressed.
 Healthy persons experience a wide range of
moods and have an equally large repertoire
of affective expressions; they feel in control
of their moods and affects.
 Mood disorders are a group of clinical
conditions characterized by a loss of that
sense of control and a subjective experience
of great distress.
 Patients with elevated mood demonstrate
expansiveness, flight of ideas, decreased
sleep, and grandiose ideas.
 Patients with depressed mood experience a
loss of energy and interest, feelings of guilt,
difficulty in concentrating, loss of appetite,
and thoughts of death or suicide.
 Other signs and symptoms of mood
disorders include change in activity level,
cognitive abilities, speech, and vegetative
functions (e.g., sleep, appetite, sexual
activity, and other biological rhythms).
 These disorders virtually always result in
impaired interpersonal, social, and
 Patients afflicted with only major
depressive episodes are said to have
major depressive disorder or unipolar
depression.
 Patients with both manic and
depressive episodes or patients with
manic episodes alone are said to
have bipolar disorder.
 The terms unipolar mania and pure
mania are sometimes used for
patients who are bipolar, but who do
not have depressive episodes.
Three additional categories of mood disorders
are:
 Hypomania
 cyclothymia
 dysthymia.
 Hypomania is an episode of manic symptoms
that does not meet the full text revision of the
fourth edition of Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR) criteria
for manic episode.
 Cyclothymia and dysthymia are defined by
DSM-IV-TR as disorders that represent less
severe forms of bipolar disorder and major
depression, respectively.
Incidence and Prevalence
 Mood disorders are common. In the most recent
surveys,
 major depressive disorder has the highest lifetime
prevalence (almost 17 percent) of any psychiatric
disorder.
 The lifetime prevalence rate of different forms of DSM-
IV-TR unipolar depressive disorder, according to the
eight major community surveys, are shown in
 Table 15.1-1. The yearly incidence of a major
depression is 1.59 percent (women, 1.89 percent; men,
1.10 percent).
 The lifetime prevalence rates of different clinical forms
of bipolar disorder are shown in Table 15.1-2.
 The annual incidence (number of new cases) of a major
depressive episode is 1.59 percent (women, 1.89
percent; men, 1.10 percent).
 The annual incidence of bipolar illness is less than 1
percent, but it is difficult to estimate, because milder
 DSM-IV-TR Criteria for Major Depressive
Episode
 Five (or more) of the following symptoms have
been present during the same 2-week period
and represent a change from previous
functioning; at least one of the symptoms is
either (1) depressed mood or (2) loss of
interest or pleasure.
Note: Do not include symptoms that are
clearly due to a general medical condition, or
mood-incongruent delusions or hallucinations.
– depressed mood most of the day, nearly every day,
as indicated by either subjective report (e.g., feels
sad or empty) or observation made by others (e.g.,
appears tearful). Note: In children and adolescents,
can be irritable mood
– markedly diminished interest or pleasure in all, or
almost all, activities most of the day, nearly every
day (as indicated by either subjective account or
– significant weight loss when not dieting or
weight gain (e.g., a change of more than 5%
of body weight in a month), or decrease or
increase in appetite nearly every day. Note:
In children, consider failure to make expected
weight gains.
– insomnia or hypersomnia nearly every day
– psychomotor agitation or retardation nearly
every day (observable by others, not merely
subjective feelings of restlessness or being
slowed down)
– psychomotor agitation or retardation nearly
every day (observable by others, not merely
subjective feelings of restlessness or being
slowed down)
– fatigue or loss of energy nearly every day
– feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or
guilt about being sick)
– diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by
subjective account or as observed by others)
– recurrent thoughts of death (not just fear of
dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a
specific plan for committing suicide
 The symptoms do not meet criteria for a mixed
episode.
 The symptoms cause clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.
 The symptoms are not due to the direct
physiological effects of a substance (e.g., a drug
of abuse, a medication) or a general medical
condition (e.g., hypothyroidism).
 The symptoms are not better accounted for by
bereavement, i.e., after the loss of a loved one,
the symptoms persist for longer than 2 months o
are characterized by marked functional
impairment, morbid preoccupation with
worthlessness, suicidal ideation, psychotic
symptoms, or psychomotor retardation.
 DSM-IV-TR Criteria for Manic Episode
 A distinct period of abnormally and
persistently elevated, expansive, or
irritable mood, lasting at least 1 week (or
any duration if hospitalization is
necessary).
 During the period of mood disturbance,
three (or more) of the following
symptoms have persisted (four if the
mood is only irritable) and have been
present to a significant degree:
– inflated self-esteem or grandiosity
– decreased need for sleep (e.g., feels rested
after only 3 hours of sleep)
– more talkative than usual or pressure to keep
 – flight of ideas or subjective experience that
thoughts are racing
– distractibility (i.e., attention too easily drawn to
unimportant or irrelevant external stimuli)
– increase in goal-directed activity (either socially,
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
buying sprees, sexual indiscretions, or foolish
business investments)
 The symptoms do not meet criteria for a
mixed episode.
 The mood disturbance is sufficiently severe
to cause marked impairment in
occupational functioning or in usual social
activities or relationships with others, or to
necessitate hospitalization to prevent harm
 The symptoms are not due to the direct
physiological effects of a substance (e.g.,
a drug of abuse, a medication, or other
treatment) or a general medical condition
(e.g., hyperthyroidism).
Note: Manic-like episodes that are clearly
caused by somatic antidepressant
treatment (e.g., medication,
electroconvulsive therapy, light therapy)
should not count toward a diagnosis of
bipolar I disorder.
 (From American Psychiatric Association.
Diagnostic and Statistical Manual of Mental
Disorders. 4th ed. Text rev. Washington,
DC: American Psychiatric Association
 DSM-IV-TR Criteria for Hypomanic
Episode
 A distinct period of persistently
elevated, expansive, or irritable mood,
lasting throughout at least 4 days, that
is clearly different from the usual
nondepressed mood.
 During the period of mood disturbance,
three (or more) of the following
symptoms have persisted (four if the
mood is only irritable) and have been
present to a significant degree:
– flight of ideas or subjective experience
that thoughts are racing
– distractibility (i.e., attention too easily
drawn to unimportant or irrelevant
external stimuli)
– increase in goal-directed activity (either
socially, at work or school, or sexually)
or psychomotor agitation
– excessive involvement in pleasurable
activities that have a high potential for
painful consequences (e.g., the person
engages in unrestrained buying sprees,
sexual indiscretions, or foolish business
investments)
 The episode is associated with an
unequivocal change in functioning that is
uncharacteristic of the person when not
symptomatic.
 The disturbance in mood and the change in
functioning are observable by others.
 The episode is not severe enough to cause
marked impairment in social or occupational
functioning, or to necessitate hospitalization,
and there are no psychotic features.
 The symptoms are not due to the direct
physiological effects of a substance (e.g., a
drug of abuse, a medication, or other
treatment) or a general medical condition
(e.g., hyperthyroidism).
Note: Hypomanic-like episodes that are
clearly caused by somatic antidepressant
treatment (e.g., medication,
 DSM-IV-TR Criteria for Mixed Episode
 The criteria are met both for a manic episode
and for a major depressive episode (except for
duration) nearly every day during at least a 1-
week period.
 The mood disturbance is sufficiently severe to
cause marked impairment in occupational
functioning or in usual social activities or
relationships with others, or to necessitate
hospitalization to prevent harm to self or
others, or there are psychotic features.
 The symptoms are not due to the direct
physiological effects of a substance (e.g., a
drug of abuse, a medication, or other
treatment) or a general medical condition (e.g.,
hyperthyroidism).
 Note: Mixed-like episodes that are clearly
caused by somatic antidepressant treatment
 DSM-IV-TR Criteria for Severity/Psychotic/
Remission Specifiers for Current (or Most
Recent) Major Depressive Episode
 Note: Code in fifth digit. Mild, moderate, severe
without psychotic features, and severe with
psychotic features can be applied only if the criteria
are currently met for a major depressive episode. In
partial remission and in full remission can be applied
to the 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.
Mild: Few, if any, symptoms in excess of those
required to make the diagnosis and symptoms result
in only minor impairment in occupational functioning
or in usual social activities or relationships with
others.
Moderate: Symptoms or functional impairment
between mild and severe.
 Severe without psychotic features: Several
symptoms in excess of those required to make the
diagnosis, and symptoms markedly interfere with
occupational functioning or with usual social
activities or relationships with others.
Severe with psychotic features: Delusions or
hallucinations. If possible, specify whether the
psychotic features are mood-congruent or mood-
incongruent:
   Mood-congruent psychotic features: Delusions
or hallucinations whose content is entirely consistent
with the typical depressive themes of personal
inadequacy, guilt, disease, death, nihilism, or
deserved punishment.
   Mood-incongruent psychotic features:
Delusions or hallucinations whose content does not
involve typical depressive themes of personal
inadequacy, guilt, disease, death, nihilism, or
deserved punishment. Included are such symptoms
as persecutory delusions (not directly related to
 Mood-incongruent psychotic features: Delusions
or hallucinations whose content does not involve
typical depressive themes of personal inadequacy,
guilt, disease, death, nihilism, or deserved
punishment. Included are such symptoms as
persecutory delusions (not directly related to
depressive themes), thought insertion, thought
broadcasting, and delusions of control.
In partial remission: Symptoms of a major
depressive episode are present but full criteria are
not met, or there is a period without any significant
symptoms of a major depressive episode lasting less
than 2 months following the end of the major
depressive episode. (If the major depressive episode
was superimposed on dysthymic disorder, the
diagnosis of dysthymic disorder alone is given once
the full criteria for a major depressive episode are no
longer met.)
In full remission: During the past 2 months, no
 DSM-IV-TR Criteria for Severity/Psychotic/
Remission Specifiers for Current (or Most Recent)
Manic Episode Note: Code in fifth digit. Mild,
moderate, severe without psychotic features, and
severe with psychotic features can be applied only if
the criteria are currently met for a 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.
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 or others.
Severe with psychotic features: Delusions or
hallucinations. If possible, specify whether the
psychotic features are mood-congruent or mood-
 Mood-congruent psychotic features: Delusions
or hallucinations whose content is entirely consistent
with the typical manic themes of inflated worth,
power, knowledge, identity, or special relationship to
a deity or famous person.
   Mood-incongruent psychotic features:
Delusions or hallucinations whose content does not
involve typical manic themes of inflated worth,
power, knowledge, identity, or special relationship to
a deity or famous person. Included are such
symptoms as persecutory delusions (not directly
related to grandiose ideas or themes), thought
insertion, and delusions of being controlled.
In partial remission: Symptoms of a manic
episode are present but full criteria are not met, or
there is a period without any significant symptoms of
a manic episode lasting less than 2 months following
the end of the manic episode.
In full remission: During the past 2 months no