Wk 4 Assignment BiPolar
Summary
This chapter has described the mood disorders, including those across the bipolar spectrum. For prognostic and treatment purposes, it is increasingly important to be able to distinguish unipolar depression from bipolar spectrum depression. Although mood disorders are indeed disorders of mood, they are much more, and several different symptoms in addition to a mood symptom are required to make a diagnosis of a major depressive episode or a manic episode. Each symptom can be matched to a hypothetically malfunctioning neuronal circuit. The monoamine hypothesis of depression suggests that dysfunction, generally due to underactivity, of one or more of the three monoamines DA, NE, or 5HT may be linked to symptoms in major depression. Boosting one or more of the monoamines in specific brain regions may improve the efficiency of information processing there, and reduce the symptom caused by that area’s malfunctioning. Other brain areas associated with the symptoms of a manic episode can similarly be mapped to various hypothetically malfunctioning brain circuits. Understanding the localization of symptoms in circuits, as well as the neurotransmitters that regulate these circuits in different brain regions, can set the stage for choosing and combining treatments for each individual symptom of a mood disorder, with the goal being to reduce all symptoms and lead to remission.
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Are mood disorders progressive?
One of the major unanswered questions about the natural history of depressive illnesses is whether they are progressive ( and ). Some observers believe that there is an increasingFigures 6-23 6-24 number of patients in mental health practices who have bipolar spectrum illnesses rather than unipolar illnesses, especially compared to a few decades ago. Is this merely the product of changing diagnostic criteria, or does unipolar depression progress to bipolar depression ( )? AFigure 6-23 corollary of this question is whether chronic and widespread undertreatment of unipolar depression, allowing residual symptoms to persist and relapses and recurrences to occur, results first in more rapidly recurring episodes of major depression, then in poor inter-episode recovery, then progression to a bipolar spectrum condition, and finally to treatment resistance ( ). ManyFigure 6-23 treatment-resistant mood disorders in psychiatric practices have elements of bipolar spectrum disorder that can be identified, and many of these patients require treatment with more than antidepressants, or with mood stabilizers and atypical antipsychotics instead of antidepressants. For patients already diagnosed with bipolar disorder, there is similar concern that the disorder may be progressive, especially without adequate treatment. Thus, discrete manic and depressive episodes may progress to mixed and dysphoric episodes, and finally to rapid cycling, instability, and treatment resistance ( ). The hope is that recognition and treatment of both unipolar and bipolarFigure 6-24 depressions, causing all symptoms to remit for long periods of time, might prevent progression to more difficult states. This is not proven, but is a major
Table 6-1 Mixed states of mania and depression
Figure 6-19. . Bipolar V is defined as major depressive episodes with hypomanic symptoms occurringBipolar V during the major depressive episode but without the presence of discrete hypomanic episodes. Because the symptoms do not meet the full criteria for mania, these patients would not be considered to have a full mixed episode, but they nonetheless exhibit a mixed presentation and may require mood stabilizer treatment as opposed to antidepressant monotherapy.
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hypothesis in the field at the present time. In the meantime, practitioners must decide whether to commit “sins of omission,” and be conservative with the diagnosis of bipolar spectrum disorder, and err on the side of undertreatment of mood disorders, or “sins of commission,” and overdiagnose and overtreat symptoms in the hope that this will prevent disease progression.
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