F30.0 Hypomania

A.   The mood is elevated or irritable to a degree that is definitely abnormal for the individual concerned and  sustained for at least four consecutive days.

B.   At least three of the following must be present, leading to some interference with personal functioning in daily living:-
(1) increased activity or physical restlessness;
(2) increased talkativeness;
(3) difficulty in concentration or distractibility;
(4) decreased need for sleep;
(5) increased sexual energy;
(6) mild spending sprees, or other types of reckless or irresponsible behaviour;
(7) increased sociability or over-familiarity.

C.   The episode does not meet the criteria for mania (F30.1 and F30.2), bipolar affective disorder
(F31.-), depressive episode (F32.-), cyclothymia (F34.0) or anorexia nervosa (F50.0).
D.   Most commonly used exclusion criteria: the episode is not attributable to psychoactive substance use (F1) or any organic mental disorder, in the sense of F0

F30.1 Mania without psychotic symptoms

A.   A mood which is predominantly elevated, expansive or irritable and definitely abnormal for the individual concerned. This mood change must be prominent and sustained for at least a week (unless it is severe enough to require hospital admission).

B.   At least three of the following must be present (four if the mood is merely irritable), leading to severe  interference with personal functioning in daily living:
(1) Increased activity or physical restlessness;
(2) Increased talkativeness ('pressure of speech');
(3) Flight of ideas or the subjective experience of thoughts racing;
(4) Loss of normal social inhibitions resulting in behaviour which is inappropriate to the circumstances;
(5) Decreased need for sleep;
(6) Inflated self-esteem or grandiosity;
(7) Distractibility or constant changes in activity or plans;
(8) Behaviour which is foolhardy or reckless and whose risks the subject does not recognize e.g. spending sprees, foolish enterprises, reckless driving;
(9) Marked sexual energy or sexual indiscretions.

C. The absence of hallucinations or delusions, although perceptual disorders may occur (e.g. subjective hyperacusis, appreciation of colours as specially vivid, etc.).

D.   Mot commonly used exclusion criteria: the episode is not attributable to psychoactive substance use (F1) or any organic mental disorder, in the sense of F0.

F30.2 Mania with psychotic symptoms

A. The episode meets the criteria for mania without psychotic symptoms (F30.1) with exception of criterion C.
B.   The episode does not simultaneously meet the criteria for schizophrenia (F20) or schizo-affective disorder, manic type (F25.0).
C.   Delusions or hallucinations are present, other than those listed as typical schizophrenic in F20

G1. 1b, c and d (i.e. delusions other than those that are completely impossible or culturally inappropriate and hallucinations, that are not in the third person or giving a running commentary). The commonest examples are those with grandiose, self-referential, erotic or persecutory content.

D.   Mot commonly used exclusion criteria: the episode is not attributable to psychoactive substance use (F1) or any organic mental disorder, in the sense of F0.A fifth character may be used to specify whether the hallucinations or delusions are congruent or incongruent with the mood:

F30.20 mania with mood congruent psychotic symptoms (such as grandiose delusions or voices telling the subject that he has superhuman powers)

F30.21 mania with mood incongruent psychotic symptoms (such as voices speaking to the subject about  affectively neutral topics, or delusions of reference or persecution).

F32 Depressive episode
G1. The depressive episode should last for at least 2 weeks.
G2. There have been no hypomanic or manic symptoms sufficient to meet the criteria for hypomanic or manic  episode (F30.-) at any time in the individual's life.
G3. Most commonly used exclusion clause. The episode is not attributable to psychoactive substance use (F10- F19) or to any organic mental disorder (in the sense of F00-F09).

Somatic syndrome
Some depressive symptoms are widely regarded as having special clinical significance and are here called "somatic".
(Terms such as biological, vital, melancholic, or endogenomorphic are used for this syndrome in other  classification.)
A fifth character (as indicated in F31.3; F32.0 and F32.1; F33.0 and F33.1) may be used to specify the presence or absence of the somatic syndrome. To qualify for the somatic syndrome, four of the following symptoms should be present:
(1) marked loss of interest or pleasure in activities that are normally pleasurable;
(2) lack of emotional reactions to events or activities that normally produce an emotional response;
(3) waking in the morning 2 hours or more before the usual time;
(4) depression worse in the morning;
(5) objective evidence of marked psychomotor retardation or agitation (remarked on or reported by other  people);
(6) marked loss of appetite;
(7) weight loss (5% or more of body weight in the past month);
(8) marked loss of libido.

A. The general criteria for depressive episode (F32) must be met.

B. At least two of the following three symptoms must be present:
(1) depressed mood to a degree that is definitely abnormal for the individual, present for most of the day and  almost every day, largely uninfluenced by circumstances, and sustained for at least 2 weeks.
(2) loss of interest or pleasure in activities that are normally pleasurable;
(3) decreased energy or increased fatiguability.
C.   An additional symptom or symptoms from the following list should be present, to give a total of at least  four:
(1) loss of confidence and self-esteem;
(2) unreasonable feelings of self-reproach or excessive and inappropriate guilt;
(3) recurrent thoughts of death or suicide, or any suicidal behaviour;
(4) complaints or evidence of diminished ability to think or concentrate, such as indecisiveness or vacillation;
(5) change in psychomotor activity, with agitation or retardation (either subjective or objective);
(6) sleep disturbance of any type;
(7) change in appetite (decrease or increase) with corresponding weight change).

A fifth character may be used to specify the presence or absence of the "somatic syndrome" (defined on page xx):

F32.00 Without somatic syndrome

F32.01 With somatic syndrome

F33 Recurrent depressive disorder
G1. There has been at least one previous episode, mild (F32.0), moderate (F32.1), or severe (F32.2 or F32.3), lasting a minimum of 2 weeks and separated from the current episode by at least 2 months free from any significant mood symptoms.
G2. At no time in the past has there been an episode meeting the criteria  for hypomanic or manic episode (F30.-).
G3. Most commonly used exclusion criteria: the episode is not attributable to psychoactive substance use (F1)  or any organic mental disorder, in the sense of F0.
It is recommended to specify the predominant type of previous episodes (mild, moderate, severe, uncertain).

F34.0 Cyclothymia

A. A period of at least two years of instability of mood involving several periods of both depression and hypomania, with or without intervening periods of normal mood.

B. None of the manifestations of depression or hypomania during such a two- year period should be sufficiently severe or long lasting to meet criteria for manic episode or depressive episode (moderate or  severe); however, manic or depressive episode(s) may have occurred before, or may develop after, such a  period of persistent mood instability.

C.    During at least some of the periods of depression at least three of the following should be present:
(1) A reduction in energy or activity;
(2)  Insomnia;
(3) Loss of self confidence or feelings of inadequacy;
(4) Difficulty concentrating;
(5) Social withdrawal;
(6) Loss of interest or enjoyment in sex and other pleasurable activities;
(7) Less talkative than normal;
(8) Pessimistic about the future or brooding over the past.
 
D.   During at least some of the periods of mood elevation at least three of the following should be present:
(1) Increased energy or activity;
(2) Decreased need for sleep;
(3)  Inflated self esteem;
(4) Sharpened or unusually creative thinking;
(5) More gregarious than normal;
(6) More talkative or witty than normal;
(7) Increased interest and involvement in sexual and other pleasurable activities;
(8) Over-optimism or exaggeration of past achievements.
Note: If desired, specify whether onset is early (in late teenage or the twenties) or late (usually between age 30 to 50 subsequent to an affective episode).

F34.1 Dysthymia

A.   A period of at least two years of constant or constantly recurring depressed mood.
Intervening periods of normal mood rarely last for longer than a few weeks and there are no episodes of  hypomania.
B.   None, or very few, of the individual episodes of depression within such a two-year period are severe enough, or last long enough, to meet the criteria for recurrent mild depressive disorder (F33.0).
C.   During at least some of the periods of depression at least three of the following should be present:

(1) A reduction in energy or activity;
(2) Insomnia;
(3) Loss of self-confidence or feelings of inadequacy;
(4) Difficulty concentrating;
(5) Often in tears;
(6) Loss of interest or enjoyment in sex and other pleasurable activities;
(7) Feeling of hopelessness or despair;
(8) A perceived inability to cope with the routine responsibilities of everyday life;
(9) Pessimistic about the future or brooding over the past;
(10) Social withdrawal;
(11) Less talkative than normal

Types of Bipolar Disorder

There are several types of bipolar disorder; all involve episodes of depression and mania to a degree.

Bipolar disorder is a lifelong illness. Episodes of mania and depression eventually can occur again, if you don't get treatment. Many people sometimes continue to have symptoms, even after getting treatment for their bipolar disorder. Here are the types of bipolar disorder:

• Bipolar I disorder involves periods of severe mood episodes from mania to depression.
• Bipolar II disorder is a milder form of mood elevation, involving milder episodes of hypomania that alternate with periods of severe depression.
• Cyclothymic disorder describes periods of hypomania with brief periods of depression that are not as extensive or long-lasting as seen in full depressive episodes.
• Mixed bipolarepisodes are periods that simultaneously involve the full symptoms of both a manic and a full depressive episode. It's marked by grandiose feelings with racing thoughts. At the same time, the person is irritable, angry, moody, and feeling bad.
• Rapid-cycling bipolar disorder is characterized by four or more mood episodes that occur within a 12-month period. Episodes must last for some minimum number of days in order to be considered distinct episodes.  Some people also experience changes in polarity from high to low or vice-versa within a single week, or even within a single day -- the full symptom profile that defines distinct, separate episodes may not be present (for example, the person may not have a decreased need for sleep), making such "ultra-rapid" cycling a more controversial phenomenon. Rapid cycling can occur at any time in the course of illness, although some researchers believe that it may be more common at later points in the lifetime duration of illness. Women appear more likely than men to have rapid cycling. A rapid-cycling pattern increases risk for severe depression and suicide attempts. Antidepressants are thought to trigger and prolong rapid cycling in bipolar disorder. However, that theory is controversial and is still being studied.

Depressive episode; Duration must be 2 weeks
Manic: Duration is of least 7 days
Hypomanic : Duration is of least 4 days
Dysthymic disorder: Duration must be 2 years
Cyclothymic Disorder: Duration must be 2 years
Bipolar I Disorder: - There should be at least one manic episode.
Bipolar II Disorder: - Presence of at least one hypomanic episode and never an episode of mania Presence of one or more major depressive episodes

Rapid cycling: - At least four episodes of mood disturbances in the previous 12 months in case of bipolar disorder

Premenstrual dysphoric disorder:

• Late luteal phase dysphoric disorder it involves
• Mood symptoms; lability, irritability, anxiety, decreased interest in activities
• Behavioral; appetite and sleep patterns
• Somatic; headache, breast tenderness and edema
• In most menstrual cycles during the past year, symptoms present during the last week of the week of luteal phase

Treatment fluoxetine and alprazolam

Seasonal affective disorder 

• Regular temporal relationship between the onset of depressive episode and a particular time of the year
• Full remission also occur at a characteristic time of the year
• This pattern has been there for at least two years
• Symptoms; increased fatigue, increased appetite, carbohydrate craving & increased sleep   

Treatment: light therapy (phototherapy) for depressive episode        
  
Pharmacological courses of depression

• Propranolal
• Digitalis
• Ethanol
• Benzodiazepies
• Oral contraceptives
• Salbutamol

Endocrine disorders

• Adrenal (cushing, addison’s disease)
• Parathyroid disorders (Hyper and hypo)
• Thyroid disorder (hypothyroidism)

Vitamin deficiencies

• Folate
• Vitamin B12
• Niacin
• Vitamin C
• Thiamine

Norepinephrine and serotonin are two neurotransmitters implicated in mood disorders Veraguth fold is peculiar or triangle shaped fold in the nasal corners of the upper eyelid. The fold is offen associated with depression.
Forgetfulness of depression is known as Pseudo dementia. It differs form dementia in
1. Sudden onset
2. No confabulations as in dementia.
3. Insight is present i.e. may be encouraged to remember
4. Don’t know answers
5. Recent memory impairment

Cognitive therapy: - Is used for the treatment of depression. Aaron Beck developed it.
Cognitive triad: - hopelessness, helplessness & worthlessness

Antidepressant medications:-
Tricyclics and tetracyclics
1. Amitriptyline
2. Clomipramine
3. Doxepin
4. Imipramine
5. Trimipramine

Tetracyclic drugs

• Amoxapine, maprotiline
• Amitriptyline is most anticholinergic and desipraimine is least Doxepin is most H1
• Antagonist

Important point to be remembered is that Amoxapine also acts on dopamine receptors, so it can cause NMS and tardive duskiness like typical antipsychotic drug.
Indications:-
1. Depression
2. Clomipramine in obsessive compulsive disorder
Non psychiatric user of Amitriptyline – Chronic pain syndrome migraine headache
Prophylaxis
Imipramine – Enuresis in children
S/E of tricyclic Antidepressants-
1. Anticholinergic side effects like dry mouth, constipation, visual changes, urinary hesitancy delirium and ocular crisis in pts narrow glaucoma
Orthostatic hypotension

Tachycardia

• Sexual dysfunction- more commonly with Clomipramine Allergic rashes.
• Death as overdose results forms cardiac toxicity.
• Desipramine met used in children less than 12 years of possible adverse cardiac effects

SSRI – Selective serotonin Reuptake inhibition

• Fluoxetine
• Fluvoxamine
• Paroxetine
• Cetalopram- most elective SSRI
• Sertraline

Uses of Fluoxetine
1.      Major depressive disorder
2.      Bipolar disorders
3.      Dysthymic compulsive disorder
4.      Trichotillomania
5.      Obsessive compulsive disorder
6.      Bulimia nervosa
7.      Panic Disorder
8.      Social phobia
9.      Substance dependence
10.     Premature ejaculation
11.     Chronic fatigue syndrome

S/E – Anorexia, occasional weight loss, diarrhea, nervousness, insomnia, anxiety, tremor, delayed ejaculation

Uses of Sertraline
1. Depression
2. Dysthymia
3. O.C.D
4. Postpartum depression
5. Post traumatic stress disorder
6. Premature ejaculation
7. Premenstrual Dysphoric disorder
8. Panic disorder

MIRTAZAPINE-

• Antidepressant
• NASSA- Noradrenergic and specific Serotonergic Antidepressant

inhibitor

Grief

Grief is a natural response to loss. It is the emotional suffering one feels when something or someone the individual loves is taken away. Grief is also a reaction to any loss. The grief associated with death is familiar to most people, but individuals grieve in connection with a variety of losses throughout their lives, such as unemployment, ill health or the end of a relationship. Loss can be categorised as either physical or abstract, the physical loss being related to something that the individual can touch or measure, such as losing a spouse through death, while other types of loss are abstract, and relate to aspects of a person’s social interactions.

Every step of the process is natural and healthy, it is only when a person gets stuck in one step for a long period of time then the grieving can become unhealthy, destructive and even dangerous. When going through the grieving process it is not the same for everyone, but everyone does have a common goal, acceptance of the loss and to always keep moving forward. This process is different for every person but can be understood in four different steps.
Shock and Denial
Shock is the initial reaction to loss. Shock is the person’s emotional protection from being too suddenly overwhelmed by the loss. The person may not yet be willing or able to believe what their mind knows to be true. This stage normally lasts two or three months.
Intense Concern
Intense concern is often shown by not being able to think of anything else. Even during daily tasks, thoughts of the loss keep coming to mind. Conversations with one at this stage always turn to the loss as well. This period may last from six months to a year.
Despair and Depression
Despair and depression is a long period of grief, the most painful and protracted stage for the griever (during which the person gradually comes to terms with the reality of the loss). The process typically involves a wide range of feelings, thoughts, and behaviors. Many behaviors may be irrational. Depression can include feelings of anger, guilt, sadness and anxiety.
Recovery
The goal of grieving is not the elimination of all the pain or the memories of the loss. In this stage, one shows a new interest in daily activities and begins to function normally day to day. The goal is to reorganize one’s life, so the loss is an important part of life rather than its center

Mania

Mania is a state of abnormally elevated or irritable mood, arousal, and/or energy levels.[1] In a sense, it is the opposite of depression. Mania is a criterion for certain psychiatric diagnoses. The word derives from the Greek "μαν?α" (mania), "madness, frenzy" and that from the verb "μα?νομαι" (mainomai), "to be mad, to rage, to be furious".

In addition to mood disorders, persons may exhibit manic behavior because of drug intoxication (notably stimulants, such as cocaine and methamphetamine), medication side effects (notably steroids and SSRIs), and malignancy. But mania is most often associated with bipolar disorder, where episodes of mania may alternate with episodes of major depression. Gelder, Mayou, and Geddes suggest that it is vital that mania be predicted in the early stages because otherwise the patient becomes reluctant to comply to the treatment. The criteria for bipolar disorder do not include depressive episodes, and the presence of mania in the absence of depressive episodes is sufficient for a diagnosis. Regardless, those who never experience depression also experience cyclical changes in mood. These cycles are often affected by changes in sleep cycle (too much or too little), diurnal rhythms, and environmental stressors.
 

Symtoms :

To be classed as a manic episode, while the disturbed mood is present at least three (or four if only irritability is present) of the following must have been consistently prominent: grand or extravagant style, or expanded self-esteem; reduced need of sleep talks more often and feels the urge to talk longer; ideas flit through the mind in quick succession, or thoughts race and preoccupy the person; over indulgence in enjoyable behaviors with high risk of a negative outcome.

The World Health Organization's classification system defines a manic episode as one where mood is higher than the person's situation warrants and may vary from relaxed high spirits to barely controllable exuberance, accompanied by hyperactivity, a compulsion to speak, a reduced sleep requirement, difficulty sustaining attention and, often, increased distractability. Frequently, confidence and self-esteem are excessively enlarged, and grand, extravagant ideas are expressed. Behavior that is out of character and risky, foolish or inappropriate may result from a loss of normal social restraint.

Treatment :

Before beginning treatment for mania, careful differential diagnosis must be performed to rule out non-psychiatric causes.Acute mania in bipolar disorder is typically treated with mood stabilizers or antipsychotic medication. Note that these treatments need to be prescribed and monitored carefully to avoid harmful side-effects such as neuroleptic malignant syndrome with the antipsychotic medications. It may be necessary to temporarily admit the patient involuntarily until the patient is stabilized. Antipsychotics and mood stabilizers help stabilize mood of those with mania or depression. They work by blocking the receptor for the neurotransmitter dopamine and allowing serotonin to still work, but in diminished capacity.

When the manic behaviours have gone, long-term treatment then focuses on prophylactic treatment to try to stabilize the patient's mood, typically through a combination of pharmacotherapy and psychotherapy. The likelihood of having a relapse is very high for those who have experienced two or more episodes of mania or depression. While medication for bipolar disorder is important to manage symptoms of mania and depression, studies show relying on medications alone is not the most effective method of treatment. Medication is most effective when used in combination with other bipolar disorder treatments, including psychotherapy, self-help coping strategies, and healthy lifestyle choices.

Lithium is the classic mood stabilizer to prevent further manic and depressive episodes. Anticonvulsants such as valproic acid, oxcarbazepine and carbamazepine are also used for prophylaxis. More recent drug solutions include lamotrigine, which is another anticonvulsant. Clonazepam (Rivotril, Ravotril or Rivatril) is also used. Sometimes atypical antipsychotics are used in combination with the previous mentioned medications as well, including olanzapine (Zyprexa) which helps treat hallucinations or delusions, Asenapine (Saphris, Sycrest), aripiprazole (Abilify), risperidone, ziprasidone, and clozapine which is often used for people who do not respond to lithium or anticonvulsants.

Verapamil, a calcium-channel blocker, is useful in the treatment of hypomania and in those cases where lithium and mood stabilizers are contraindicated or ineffective.Verapamil is effective for both short-term and long-term treatment.

Depression

Depression is a state of low mood and aversion to activity that can have a negative effect on a person's thoughts, behavior, feelings, world view and physical well-being. Depressed people may feel sad, anxious, empty, hopeless, worried, helpless, worthless, guilty, irritable, hurt or restless. They may lose interest in activities that once were pleasurable, experience loss of appetite or overeating, have problems concentrating, remembering details, or making decisions and may contemplate or attempt suicide. Insomnia, excessive sleeping, fatigue, loss of energy, or aches, pains or digestive problems that are resistant to treatment may also be present.

Depressed mood is not necessarily a psychiatric disorder. It is a normal reaction to certain life events, a symptom of some medical conditions and a side effect of some medical treatments. Depressed mood is also a primary or associated feature of certain psychiatric syndromes such as clinical depression.
 

Causes :

Life events

Life events and changes that may precipitate depressed mood include menopause, financial difficulties, job problems, relationship troubles, separation and bereavement.

Medical treatments

Certain medications are known to cause depressed mood in a significant number of patients. These include Hepatitis C drug therapy and some drugs used to treat high blood pressure, such as beta-blockers or reserpine.

Depressed mood can be the result of a number of infectious diseases and physiological problems including hypoandrogenism (in men), Addison's disease, Lyme disease, multiple sclerosis, sleep apnea and disturbed circadian rhythm. It is often one of the early symptoms of hypothyroidism (reduced activity of the thyroid gland). Chronic pain causes depression. For a discussion of non-psychiatric conditions that can cause depressed mood, see Depression (differential diagnoses).

Psychiatric syndromes

A number of psychiatric syndromes feature depressed mood as a main symptom. The mood disorders are a group of disorders considered to be primary disturbances of mood. These include major depressive disorder (MDD; commonly called major depression or clinical depression) where a person has at least two weeks of depressed mood or a loss of interest or pleasure in nearly all activities; and dysthymia, a state of chronic depressed mood, the symptoms of which do not meet the severity of a major depressive episode. Another mood disorder, bipolar disorder, features one or more episodes of abnormally elevated energy levels, cognition and mood, but may also involve one or more depressive episodes.

Outside the mood disorders:

Borderline personality disorder commonly features depressed mood; adjustment disorder with depressed mood is a mood disturbance appearing as a psychological response to an identifiable event or stressor, in which the resulting emotional or behavioral symptoms are significant but do not meet the criteria for a major depressive episode; and posttraumatic stress disorder, an anxiety disorder that sometimes follows trauma, is commonly accompanied by depressed mood.