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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. THOUGHTa. 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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Treatment1-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 disorders1-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 EffectsGranulocytosis, 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