18 - Other affective disorders

Other affective disorders

© SPMM Course o Rapid cycling: When at least four episodes of bipolar disorder occur within a period of one year, the condition is described  as  ‘rapid  cycling’.  Some  patients  with BPAD have more than 4 episodes per year; they are called rapid cyclers. 70-80% of rapid cyclers are women. Some of the factors associated with the rapid cycling include the use of tricyclic anti-depressant, low thyroxine level, being a female patient, Bipolar type 2 pattern of illness and the presence of neurological disease. Ultra-rapid cycling refers to the situation when fluctuations are over days or even hours. o Postpartum onset refers to the onset of mania, hypomania or depression with 4 weeks of childbirth. o Seasonal pattern refers to recurrences over several years with most episodes typically start (and end) at the same time each year.

Secondary Mania: This can occur as a result of misuse of alcohol or illicit drugs and can also occur with some prescribed drugs such as Levodopa and corticosteroids. The drug induced state wanes with the clearance of the drug responsible. It can also occur in certain organic conditions such as thyroid disease, multiple sclerosis and lesions involving cortical and or subcortical areas of the brain. Bipolar 3 is a variant used to describe minimal depression complicated by antidepressant-induced hypomania – these patients fall into bipolar spectrum (in ICD: this is coded as unspecified type). Other affective disorders Persistent affective disorders: This includes dysthymia and cyclothymia respectively for unipolar and bipolar patterns of symptoms that fail to meet criteria for severity but which are of long duration and sufficient to cause impairment. Dysthymia (ICD-10)/dysthymic disorder (DSM-IV): Chronic, mildly depressed mood and diminished enjoyment, not severe enough to be considered a depressive illness. Clinical features include depressed mood (< 2yrs), Reduced/increased appetite, Insomnia/hypersomnia, reduced energy/fatigue, Low self-esteem, Poor concentration and thoughts of hopelessness. Double Depression describes episodes of major depression superimposed on Dysthymia; the prognosis and treatment response may be worse. Cyclothymia:  There  is  also  a  subclinical  presentation  ”cyclothymia”  in  which  an individual may experience oscillating high and low moods, without ever having a significant manic or depressive episode (numerous periods of mild depression and mild elation) and not sufficiently severe or DSM-5 AND BIPOLAR DISORDER Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as mood Separate description of mixed episode has  been  removed.  A  new  specifier  “with   mixed  features”  has  been  added:  to   qualify for this specifier, there is no need to simultaneously fulfill criteria for both mania and major depressive episode. Presence of some features of the opposite pole of mood disturbance is sufficient.

© SPMM Course prolonged to fulfill the criteria for bipolar affective disorder or recurrent depressive disorder. An individual usually perceives these mood swings as being unrelated to life events.

Seasonal Affective Disorder (SAD) is included in ICD-10 in the Annex. Many patients exhibit a seasonal pattern for their affective illness. The classical presentation is depression with reversed biological features in winter. These do not constitute SAD. To diagnose SAD, ICD-10 specifies that 3 or more affective episodes must occur, with onset within the same 90 day period of the year, for 3 or more consecutive years. Remissions should occur within a defined 90-day period of the year. Seasonal episodes substantially outnumber any non-seasonal episodes that may occur. The affective episode is most commonly depressive in nature. Atypical features like hypersomnia, increased appetite, carbohydrate craving and weight gain are common. Most commonly, the onset is in autumn/winter (when daylight is less), and resolution is in spring/summer (when daylight is more). Phototherapy is a treatment that is popular in SAD. Bright light (10,000 lux) is considered to be superior to dim light. Daily exposure is usually for 1 to 2 hours. The benefit may become apparent within a few days. Maintenance treatment is given for the next few months until the usual time of remission.

DSM-5 AND DYSTHYMIA Dysthymia of DSM-IV is now reclassified as persistent depressive disorder, a diagnosis that includes both chronic major depressive disorder and the previous dysthymic disorder.