A friend and I were having this discussion about the differences between Bipolar I and II, and I had to revert to my trusty pocket version of the DSM to remind myself.
Bipolar I is the most extreme of the disorders. In order to receive a diagnosis of Bipolar I the individual must have at least one manic episode. MANIC is the key term here- HYPOMANIC is not the same.
Hypomania can have symptoms of rapid speaking, racing ideas, not sleeping, and surges of energy. Individuals who are hypomanic are usually able to keep up with their social and occupational obligations.
Mania is intense and often frightening. Individuals may lose touch with reality, believing they are a deity, on a mission from a deity (delusions of grandeur), or experience a psychotic break. They may fly into rages. They may engage in dangerous and destructive behaviors such as abusing stimulants (cocaine, speed) or reckless driving. They may spend money with abandon and may ruin their financial lives in a matter of days.
A mixed episode is when mania and the depressive state are happening at the same time. Just thinking about this occurring is a nightmare for me. Visualize a person in a very foul, depressed, hopeless mood and combine it with racing thoughts and raging energy. Mixed episodes have symptoms such as panic, paranoid delusions, suicidal ideation, and rage.
Ok, so back to Bipolar I and II.
Bipolar I must have had at least one manic episode. A depressive episode is not needed for the diagnosis, but will usually be present at least once.
Bipolar II must have had at least one hypomanic episode and one depressive episode.
Cyclothymia could be seen as Bipolar II Lite. There must be hypomanic episodes and depressive episodes, but the depressive episodes do not need to be as severe as they are for Bipolar II.
Showing posts with label suicidal ideation. Show all posts
Showing posts with label suicidal ideation. Show all posts
Sunday, December 21, 2008
Sunday, November 23, 2008
Depression and Dysthymic Disorder
The criteria for the two disorders follow, directly from the DSM-IV TR. (emphasis added) An explanation follows at the end.
The criteria for Dysthymic Disorder is:
A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
1. poor appetite or overeating
2. insomnia or hypersomnia
3. low energy or fatigue
4. low self-esteem
5. poor concentration or difficulty making decisions
6. feelings of hopelessness
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
D. No Major Depressive Episode (see p. 356) has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission.
Note: There may have been a previous Major Depressive Episode provided there was a full remission (no significant signs or symptoms for 2 months) before development of the Dysthymic Disorder. In addition, after the initial 2 years (1 year in children or adolescents) of Dysthymic Disorder, there may be superimposed episodes of Major Depressive Disorder, in which case both diagnoses may be given when the criteria are met for a Major Depressive Episode.
E. There has never been a Manic Episode (see p. 362), a Mixed Episode (see p. 365), or a Hypomanic Episode (see p. 368), and criteria have never been met for Cyclothymic Disorder.
F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
G. 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).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
* Early Onset: if onset is before age 21 years
* Late Onset: if onset is age 21 years or older
The criteria for a major depression episode is:
A. 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.
1. 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.
2. 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 observation made by others)
3. 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.
4. insomnia or hypersomnia nearly every day
5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. fatigue or loss of energy nearly every day
7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. 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
B. The symptoms do not meet criteria for a Mixed Episode (see p. 365).
# The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. 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).
D. 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 or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
So there is a very marked difference between Dysthymic Disorder and a Major Depression Episode. A huge difference is that in order to get the dysthymic diagnosis, one has to display the symptoms almost everyday for two years! For a major depression episode, the individual must show five symptoms nearly every day for two weeks. Personally, I think the time frame difference is a bit too much... two weeks for one and two years for another? I suppose if I wrote the book I'd lessen the time period for Dysthymic Disorder to maybe a year. But once again, the writers of the book did not ask me.
There are some other key points to remember here. When any mood change happens, be it depression, agitation, mania, etc., it is important to screen for substance use; both prescription and recreational. I had a therapist (who was a social worker) tell me that chronic marijuana use can mirror Dysthymic Disorder. I haven't seen the research on this, but it sounds plausible. And having experienced taking Topamax, I can say first hand that prescriptions can not only make you feel depressed but actually slow your psychomotor functioning. There are also medical conditions that would cause mood changes, such as hyper or hypothyrodism, brain tumors, even UTIs in the elderly. Lastly, when a patient presents with depressive symptoms it is imperative to screen for possible manic or hypomanic episodes.
The criteria for Dysthymic Disorder is:
A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
1. poor appetite or overeating
2. insomnia or hypersomnia
3. low energy or fatigue
4. low self-esteem
5. poor concentration or difficulty making decisions
6. feelings of hopelessness
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
D. No Major Depressive Episode (see p. 356) has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission.
Note: There may have been a previous Major Depressive Episode provided there was a full remission (no significant signs or symptoms for 2 months) before development of the Dysthymic Disorder. In addition, after the initial 2 years (1 year in children or adolescents) of Dysthymic Disorder, there may be superimposed episodes of Major Depressive Disorder, in which case both diagnoses may be given when the criteria are met for a Major Depressive Episode.
E. There has never been a Manic Episode (see p. 362), a Mixed Episode (see p. 365), or a Hypomanic Episode (see p. 368), and criteria have never been met for Cyclothymic Disorder.
F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
G. 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).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
* Early Onset: if onset is before age 21 years
* Late Onset: if onset is age 21 years or older
The criteria for a major depression episode is:
A. 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.
1. 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.
2. 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 observation made by others)
3. 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.
4. insomnia or hypersomnia nearly every day
5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. fatigue or loss of energy nearly every day
7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. 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
B. The symptoms do not meet criteria for a Mixed Episode (see p. 365).
# The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. 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).
D. 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 or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
So there is a very marked difference between Dysthymic Disorder and a Major Depression Episode. A huge difference is that in order to get the dysthymic diagnosis, one has to display the symptoms almost everyday for two years! For a major depression episode, the individual must show five symptoms nearly every day for two weeks. Personally, I think the time frame difference is a bit too much... two weeks for one and two years for another? I suppose if I wrote the book I'd lessen the time period for Dysthymic Disorder to maybe a year. But once again, the writers of the book did not ask me.
There are some other key points to remember here. When any mood change happens, be it depression, agitation, mania, etc., it is important to screen for substance use; both prescription and recreational. I had a therapist (who was a social worker) tell me that chronic marijuana use can mirror Dysthymic Disorder. I haven't seen the research on this, but it sounds plausible. And having experienced taking Topamax, I can say first hand that prescriptions can not only make you feel depressed but actually slow your psychomotor functioning. There are also medical conditions that would cause mood changes, such as hyper or hypothyrodism, brain tumors, even UTIs in the elderly. Lastly, when a patient presents with depressive symptoms it is imperative to screen for possible manic or hypomanic episodes.
Tuesday, November 18, 2008
Suicide Prevention
Behavioral warnings of suicidal ideation:
• A tendency toward isolation and social withdrawal
• Increasing substance abuse
• Expression of negative attitudes toward self
• Expression of hopelessness or helplessness
• Loss of interest in usual activities
• Giving away valued possessions
• Expression of a lack of future orientation: "It won't matter soon anyway."
• For someone who has been very depressed, when that depression begins to lift, the individual may be at INCREASED risk of suicide, as the individual will have the psychological energy to follow-through on suicidal ideation.
People with untreated severe mental illness are at risk of suicide. Possibly symptoms of mental illness may include:
• Extreme personality changes
• Loss of interest in activities that used to be enjoyable
• Significant loss or gain in appetite
• Difficulty falling asleep or wanting to sleep all day
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Withdrawal from family and friends
• Neglect of personal appearance or hygiene
• Sadness, irritability, or indifference
• Having trouble concentrating
• Extreme anxiety or panic
• Drug or alcohol use or abuse
• Aggressive, destructive, or defiant behavior
• Poor school performance
• Hallucinations or unusual beliefs
College students who commit suicide often do not have effective coping mechanisms. Because of this, students are at the highest risk of suicide 48 hours after a triggering event. Triggering events are stressful events that the student cannot effectively cope with. Examples of triggering events are, but are not limited to: death of a friend or family member, failing school, family crisis, a break-up with a significant other, and fights with friends.
If you suspect someone may commit suicide, ask them. If they have, ask if they have a plan. The more specific the plan, the more likely they are to follow through. If they have a plan, find out if they have the means to execute the plan. If the plan is specific and the means are readily available and they have set the time: you MUST take the person to a mental health professional or the emergency room. If you are on the phone with them, call 911.
If the individual has a plan but you assess the threat to not be immediate, you must help the person seek help. Individuals overwhelmed with suicidal ideation are not capable of seeking help for themselves. Drive them to a mental health facility or walk them to a walk-in counselor. Reassure them that while the pain they are feeling is overwhelming, it can get better.
Adapted from:
National Alliance on Mental Illness
http://www.nami.org/Content/ContentGroups/Helpline1/Teenage_Suicide.htm
The Trevor Project
http://www.thetrevorproject.org/how_to_help_someone.aspx
• A tendency toward isolation and social withdrawal
• Increasing substance abuse
• Expression of negative attitudes toward self
• Expression of hopelessness or helplessness
• Loss of interest in usual activities
• Giving away valued possessions
• Expression of a lack of future orientation: "It won't matter soon anyway."
• For someone who has been very depressed, when that depression begins to lift, the individual may be at INCREASED risk of suicide, as the individual will have the psychological energy to follow-through on suicidal ideation.
People with untreated severe mental illness are at risk of suicide. Possibly symptoms of mental illness may include:
• Extreme personality changes
• Loss of interest in activities that used to be enjoyable
• Significant loss or gain in appetite
• Difficulty falling asleep or wanting to sleep all day
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Withdrawal from family and friends
• Neglect of personal appearance or hygiene
• Sadness, irritability, or indifference
• Having trouble concentrating
• Extreme anxiety or panic
• Drug or alcohol use or abuse
• Aggressive, destructive, or defiant behavior
• Poor school performance
• Hallucinations or unusual beliefs
College students who commit suicide often do not have effective coping mechanisms. Because of this, students are at the highest risk of suicide 48 hours after a triggering event. Triggering events are stressful events that the student cannot effectively cope with. Examples of triggering events are, but are not limited to: death of a friend or family member, failing school, family crisis, a break-up with a significant other, and fights with friends.
If you suspect someone may commit suicide, ask them. If they have, ask if they have a plan. The more specific the plan, the more likely they are to follow through. If they have a plan, find out if they have the means to execute the plan. If the plan is specific and the means are readily available and they have set the time: you MUST take the person to a mental health professional or the emergency room. If you are on the phone with them, call 911.
If the individual has a plan but you assess the threat to not be immediate, you must help the person seek help. Individuals overwhelmed with suicidal ideation are not capable of seeking help for themselves. Drive them to a mental health facility or walk them to a walk-in counselor. Reassure them that while the pain they are feeling is overwhelming, it can get better.
Adapted from:
National Alliance on Mental Illness
http://www.nami.org/Content/ContentGroups/Helpline1/Teenage_Suicide.htm
The Trevor Project
http://www.thetrevorproject.org/how_to_help_someone.aspx
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