MANIC EPISODE
-Characterized by abnormal elevated expanded
or irritable mood for specific period of time with
accompanied symptoms.
-This disorder is severe & produces a
disturbance in vocational & social performance
of person & admission is needed to prevent him
from harming himself & others.
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Diagnoses
-Abnormal & persistent elevated, expansive or
irritable mood for at least one week.
-Presence of at least 3 symptoms of the following:
a-Inflated self esteem & grandiosity.
b-Lack of need for sleep (feels comfortable after
few hours).
c-Talkative & pressured speech.
d-Racing or flight of ideas.
e-Distractible.
f-Hyperactive: socially, sexually , agitated.
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-Main feature of mania is a period of
elevated, expansive or irritable mood.
-Occurs in episodes with periods of
normal mood or alternates with periods
of depression.
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CLINICAL PICTURE
-Onset usually rapid, pt. is unaware of his inappropriate
behavior without regard to social or moral conventions.
-Sleep is disturbed, pt. may stay awake all night with no
signs of exhaustion.
-Appetite usually increased, but if hyperactivity continues
a long time weight loss may occur.
-Sexual interest & activity are both increased, pt. may
become dis-inhibited & commit unlawful acts.
-Hyper-sexuality is evident in the way they speak, dress ,
& behave with others.
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MENTAL STATE EXAMINATION (MANIA)
I. GENERAL APPEARANCCE:
-Manic pts. are hyperactive, have increased
amount of energy & seem never to get tired.
-They may dress in colorful but inappropriate
clothes.
-Female pts. may use a lot of make up.
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2. MOOD AND AFFECT:
-Mood is elevated, expansive.
-They express their feelings without restraint.
-May show lability.
-Elation: feeling of confidence and enjoyment.
-Euphoria: feeling of intense elation or
happiness & grandeur.
-May show Irritability & intolerance to
frustration.
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3. SPEECH:
-The speech is rapid & difficult to interrupt
(Pressure of speech).
-It may become full of jokes, rhymes, & plays on
words.
-Speech may become incomprehensible (word
salad).
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4. THOUGHT
a. Thought content:
-Thought content is going with elevated mood, & contains
high self-esteem & self-confidence & belief in great
abilities & talents.
-Delusions of grandiosity may be present (sometimes
religious type).
-Delusions of persecution may occur & are usually mood
congruent (Pt. believes that he is chosen by God to
correct the world & that people against him because they
envy him).
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b. Thought process
-Thinking is rapid & may show flight of ideas, pt.
moves from one thought & others with little
connection.
-Clang association between thoughts, that are
related by similarity in sound, but not in
meaning.
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5. PERCEPTION
-Hallucination may occur in mania, they are
usually of religious or sexual type.
Ex: Seeing a light coming down from the sky or
hearing God telling them that they are great.
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6. COGNITION AND MEMORY
-Manic pts. are usually oriented to x3.
-Poor concentration & easily distracted by
environmental stimuli.
-Memory is usually intact.
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7. INSIGHT AND JUDGMENT
- Insight & judgment are impaired.
-Manic pt. may break the law to do dangerous
acts with little regard to consequences.
-May put his hand in fire to prove that he is
strong.
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8. IMPULSE CONTROL
-Impulsive behavior is common in mania.
-Manic pts. threat & attack others if they were
frustrated.
-Suicide sometimes occurs in mania.
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9. RELIABILITY
-Information from manic pts. are not reliable.
-They tend to lie & try to deceive interviewer.
-Reliable data should be taken form family,
relatives & other sources.
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HYPOMANIC EPISODE
-Characterized by:
1-Obsvious period of elevated & expanded or
irritable mood continues for at least 4 days
which differs clearly than usual.
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2-During mood disturbance or irritability 3 or 4 of
the following symptoms should be present:
-Inflated self-esteem or grandiosity.
-Lack of need to sleep (feels comfortable after few
hours of sleep).
-Talkative or pressured speech.
-Flight of ideas or racing thoughts.
-Distractibility.
-Hyperactive (socially, vocationally, sexually) or
agitated.
-Participation in happy activities with painful results.
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3-The episode connected by change (to a degree) in
vocational performance.
4-Mood disturbance & vocational change noticed by
others.
5-The episode is not severe to make a defect or
disturbance in his work and there is no psychotic
symptoms.
Note: Symptoms of hypomanic episode are the same as
in manic episode but with difference in period & severity
(Hypomania is less in severity & longer in period).
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Prognosis:
-Usually the episode starts in early twenties.
-Usually the onset is sudden & symptoms quickly become
severe and dangerous.
-During severity of symptoms, pt. needs protection from
harming himself & others because he has poor judgment
& hyperactivity for which admission to hospital is needed.
-One important complication is substance abuse.
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Treatment
1-Drugs:
- Antipsychotic drugs or ECT .
- Lithium Bicarbonate.
*Notice: It is necessary that anti-psychotics
continue with lithium bicarbonate for one week
because lithium doesn’t give its effect before 5days.
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2- Psychotherapy:
-Supportive psychotherapy is recommended.
3- Social therapy:
-Helping pt. socially & solving his social
problems & establishing appropriate
environmental changes to decrease suffering.
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Cyclothymic Disorder
-Chronic mood disturbance of at least 2 year’s
duration.
-Many episodes of hypomanic symptoms,
depressed mood & anhedonia.
-These symptoms are less severe or intense than
those in major depressive or manic episodes.
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Other types of mood disorders
Melancholic depression
-Anhedonia & lack of reactivity to any pleasurable
stimulus.
-Depression is worse in the morning.
-Sleep disturbance of early morning.
-Awakening at least 2 hrs. before usual time.
-Marked psychomotor retardation or agitation.
-Significant wt. loss or less appetite.
-Excessive guilt.
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Atypical depression
-Mood reactivity: Ability to react to positive
stimuli.
-Significant wt. gain or in appetite.
-Hypersomnia.
-Leaden paralysis (heavy feeling in arms & legs).
-Long-standing pattern of being sensitive to
interpersonal rejection.
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Seasonal Affective Disorder
-Regular, temporal r/s b/w onset & remission of
episode of major depression at a particular time
of the year.
-Pattern must be evident for 2 consecutive years
with no intervening, non-seasonal episodes.
-Client with SAD often develop depression
during October or November and find it
remitting in Mach or April
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Post-Partum Mood Disorder
-Includes depression or mania, following the
birth of a child.
-Usually occurs within 4 weeks of the birth and
having symptoms of depression or mania.
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Prognosis for mood disorder
-Uni-polar disorder recurrent disorder tends to recur, &
episode lasts 13 months without treatment.
-With treatment it lasts around 3 months.
-As pt. becomes older, episodes become more frequent.
-Prognosis for major depressive disorder is good. It can
be well-controlled by using medications, psychotherapy.
-Dysthymia often continues for years before individuals
seek assistance for their symptoms.
-Over 50% of persons with dysthymia go on to develop
major depression.
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Treatment of affective disorders
1-Hospitalization:
-Hospitalization is indicated if:
a) There is a need for diagnostic procedures.
b) Risk of suicide or homicide.
c) Retarded pts. or disorganized hyperactive
manic pts. who cannot care for themselves.
d) History of rapid progression of symptoms
with no family or social support.
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2-Psychosocial Therapy:
-Combination of drugs & psychotherapy is most effective
treatment.
Cognitive Psychotherapy
-Aims to help pt. identifies & tests negative cognition
about his self, world & future, & develops more flexible &
positive ways of thinking.
Psychoanalytic Psychotherapy
-The goal is to make a change in personality structure, to
improve trust & develop coping mechanisms.
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Family Therapy
-Indicated if there is relation b/w pt.'s symptoms
& family interactions.
-Family therapy examines the role of pt. in the
family & how family is maintaining pt.'s
depression.
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3-Pharmachotherapy:
a) Tricyclic Antidepressants TCA’s:
Mode of Action: Inhibit re-uptake of nor-epinephrine &
serotonin in synapses, increasing their concentration.
-There is a delay in action for up to 2 or 3 weeks & pt.
should be encouraged to take the medication even if
there is no rapid response.
-Treatment is started with a low dose and then gradually
increased to get the maximum effect.
-There usual dose is 75 to 150 mg/day, but some pts. may
need up to 300 mg/day.
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Side effects: due to blocking effect on
cholinergic & alpha-adrenergic receptor, include:
-Dry mouth, blurred vision, tachycardia,
constipation, postural hypotension, drowsiness
& impaired sexual function.
-The most dangerous side effects are those on
heart in high doses a fatal arrhythmia may occur.
-Ex: Imipramine (Tofranil), Amitriptyline (Elatrol),
Clomipramine (Anfranil)
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b) Monamine Oxidase Inhibitors (MAO’s):
-These are not used regularly, only after a trial of
two TCA ‘s and ECT have failed.
-Their use decreased because of their serious
side effects.
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Mode of Action: They act by inhibiting the enzyme
monamine oxidase.
-Interaction with other drugs: They interact with
foods containing high amount of Tyramine (cheese,
beans), & drugs like amphetamine, epiphedrine and
causing a hypertensive crisis.
-With opiates causing severe hypotension.
-With insulin causing hypoglycemia.
Examples: Phenelzene (Nadil), Tranacyle Sulphate
(Parnate).
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c) Lithium Salts:
-Used mainly in prophylaxis of recurrent
mood disorders especially Bipolar Disorder.
-Also used in acute management of mania.
-Dose is 600-1800 mg of Lithium Carbonate
or Citrate given orally.
-Plasma level estimation is essential because
the therapeutic level is (0.4-0.8) mmole,
while the lethal level is 1.5 mmole.
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Side Effects
Granulocytosis, tremors, drowsiness, headache,
ataxia & slurred speech, epileptic seizures, skin
rash, hair fall, nausea, diarrhea, thirst, metallic
taste, ECG changes, arrhythmia, hypotension,
Hypothyrodism, hyperglycemia.
d) ECT
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