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unillustratedadventures · 4 years

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Bipolar Disorders

Bipolar disorders are the diagnosable mental disorders in which, among other things, mania or hypomania is centrally involved. Put simply, one has a bipolar disorder just in case one has been impaired or dysfunctional due to an elevated or irritable mood that involved increased energy or activity, together with sufficiently many symptoms of excess in relation to such a mood (i.e. symptoms of mania/hypomania). Typically, individuals who have had such manic/hypomanic symptoms have also had symptoms of excessively negative or anhedonic mood (or, in other words, symptoms of major depression). For this reason, bipolar disorders used to be collectively referred to as ‘manic depression’.

In DSM (e.g. in DSM-IV), bipolar disorders had been grouped with major depressive disorder under the heading ‘mood disorders’. This certainly makes sense, since disordered mood is an important factor in all of these disorders. Furthermore, major depressive episodes, which of course are centrally involved in major depressive disorder, are common in bipolar I and diagnostically required for bipolar II. Such connections between bipolar and depressive disorders are sometimes acknowledged, to a degree, with the use of the term ‘unipolar depression’ to refer to major depression.

However, in the newest edition of DSM (DSM-5), bipolar disorders are given their own separate chapter, so that the chapter Bipolar and Related Disorders occurs right after the chapter Schizophrenia Spectrum and Other Psychotic Disorders, and right before the chapter Depressive Disorders. This reflects the fact that bipolar disorders have important things in common with the disorders in both of these adjacent chapters. In particular, bipolar disorders act as something of a bridge between schizophrenia-related and psychotic disorders and depressive disorders—in terms of symptoms, but also in terms of heritability factors (i.e. family history and genetics).

Regarding heritability factors, there is substantial sharing of such factors between all of these disorders, with sharing at its highest between schizophrenia-related disorders and bipolar disorders, and between bipolar disorders and depressive disorders.

Regarding symptomatology, the connections among the disorders are largely straightforward. I have already touched on symptom-based connections between bipolar and depressive disorders. Specifically, I mentioned that both bipolar and depressive disorders involve disordered mood as a primary feature, and that major depression is clearly involved in the symptomatology of major depressive disorder (by definition), bipolar II (also by definition), and bipolar I (by observed correlation).

Bipolar disorders also have symptom-based connections to schizophrenia-related and psychotic disorders. In many respects, the schizophrenia-related disorder to which they have the strongest connections is schizoaffective disorder. This makes sense, of course, given that schizoaffective disorder basically combines schizophrenia with a mood disorder—bipolar or depressive—in such a way that the mood component and the schizophrenic-psychotic component are sufficiently independent. More generally, the connections between bipolar and schizophrenia-related disorders boil down to:

abnormalities in systems of emotion and/or motivation (which is necessarily diagnostic in bipolar and potentially diagnostic in schizophrenia)

disordering of cognition and/or speech (which is a diagnostic symptom of most presentations of schizophrenia, and potentially diagnostic in bipolar during mood episodes, particularly mania/hypomania)

psychotic symptoms, i.e. delusions or hallucinations (which are necessarily diagnostic in schizophrenia and potentially diagnostic in bipolar)

In relation to psychosis as it occurs in bipolar disorders: per my post on mania and hypomania, psychosis is often involved in manic episodes, and is one of the ways in which a manic/hypomanic episode qualifies more specifically as manic. However, psychotic symptoms are also occasionally involved in major depressive episodes. Psychotic depression happens to be more common in the course of bipolar disorders than in the course of major depressive disorder. Accordingly, even the nature of depressive episodes suggests a closer link between bipolar disorders and schizophrenia-related disorders, by way of psychosis and the potential thereof. (Interestingly, psychotic depression also seems to be more common in bipolar I, for which major depressive episodes are not diagnostically required but mania is diagnostically required, than in bipolar II, for which major depressive episodes are diagnostically required but mania is diagnostically precluded.)

In this post, I shall only be covering bipolar I, bipolar II, and cyclothymic disorders. DSM-5 (p. 123–9) defines these disorders as follows.

Bipolar I Disorder

An individual has bipolar I just in case:

She/he has had at least one episode of mania (as defined here), a period of excessively elevated or irritable mood that lasts at least one week or requires hospitalisation, pervasively involves increased energy or activity, has psychotic features or leads to hospitalisation or marked functional impairment, and pervasively involves at least three symptoms from among inflated self-esteem, decreased need for sleep, increased speech, racing thoughts, distractibility, increased outward activity, and recklessness.

This episode is not better explained by a schizophrenia-related or psychotic disorder.

Bipolar II Disorder

An individual has bipolar II just in case:

She/he has never had an episode of mania.

She/he has had at least one episode of hypomania (as defined here), a period of excessively elevated or irritable mood that lasts at least four days, pervasively involves increased energy or activity, does not have psychotic features or lead to hospitalisation or marked functional impairment, and pervasively involves at least three symptoms from among inflated self-esteem, decreased need for sleep, increased speech, racing thoughts, distractibility, increased outward activity, and recklessness.

She/he has had at least one episode of major depression (as defined here), a period of mood-related distress or impairment that lasts at least two weeks, and pervasively involves at least five symptoms that must include persisting negative mood or loss of interest or pleasure (or both), together with some combination of appetite disturbance, sleep disturbance, psychomotor disturbance, fatigue, negative self-appraisal, cognitive-executive disturbance, and suicidal ideation.

Significant distress or impairment were caused by these episodes of hypomania and major depression (due to the major depressive symptoms or the unpredictability of frequent alternation between major depression and hypomania).

These episodes are not better explained by a schizophrenia-related or psychotic disorder.

Cyclothymic Disorder

An individual has cyclothymic disorder just in case:

She/he has never had a full episode of mania, hypomania, or major depression (i.e. she/he has never met the full criteria for any such episode).

She/he has frequently had hypomanic and major depressive symptoms: during a continuous period lasting two years (or one year in children and adolescents), there have been numerous distinct manifestations of hypomanic symptoms (without meeting full criteria for hypomania) as well as numerous distinct manifestations of major depressive symptoms (without meeting full criteria for major depression).

During this period, hypomanic or major depressive symptoms have been present at least half the time, and the individual has not been without hypomanic or depressive symptoms for more than two months at a time.

These symptoms have caused clinically significant distress or impairment in social, occupational, or other important areas of functioning.

They are not better explained by a schizophrenia-related or psychotic disorder.

They are not attributable to the physiological effects of a substance or another medical condition.

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Next: diagnostic and associated features, development and course, risk factors, etc., of bipolar disorders

#bipolar disorder #bipolar I #bipolar II #cyclothymic disorder #mania #hypomania #major depression #schizophrenia #psychosis #mood disorder #psychotic disorder #emotional dysregulation #dsm #dsm-5 #symptoms #diagnostic criteria

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verdigrisprowl · 6 years

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Dec 18 Odothon Part 7 - DS9 S6E5 S6E6 S6E11 S7E6

Their star is back in his right mind, to Prowl’s great relief; and Prowl hopes he stays there. But he’s still concerned. He fell so easily the first time.

There is a possibility that said star’s home planet might die off of natural causes, leaving him the only person to rule their empire. Intriguing possibility. Could be utilized on Cybertron. Prowl doubts the moral Soundwave wants him to take away from the show is “kill all other Cybertronians and assume their role in the galactic community,” so he’s waiting to see how this turns out.

Today FakeProwl 5:03 pm *ping ping can he come over plz* ItsyBitsySpyers 5:03 pm *Well, that answers the question of whether or not Prowl still trusts him enough to come over and watch.*

*Come on in. He's already settled and waiting.* FakeProwl 5:04 pm *he appears straight on the couch this time.* Ready. ItsyBitsySpyers 5:04 pm {{S6E5 Favor The Bold}} FakeProwl 5:04 pm *He lost sleep over Odo. He needs to know.* ItsyBitsySpyers 5:06 pm *Greeting ping and visor off.* FakeProwl 5:06 pm *Greeting/permission ping.* FakeProwl 5:08 pm ... Even if they do retake DS9 as soon as possible... I'm concerned that by the time they do, Odo will already be working for the other side. FakeProwl 5:08 pm *"concerned," he says, oh so calmly.* ItsyBitsySpyers 5:10 pm [[Retaking it will be difficult without inside help. The Founder was in Odo's room when Kira explained her plans, and she is not a forgiving figure.]] FakeProwl 5:11 pm No, she's not. FakeProwl 5:12 pm ... Is this an intervention or a retaliation? Well. It wasn't a successful one, whatever it is. ItsyBitsySpyers 5:13 pm [[Unfortunately not.]] FakeProwl 5:16 pm *Grimaces.* Somebody needs to break down that door. He's doing nothing but interacting with a single person who's trying to manipulate him. ItsyBitsySpyers 5:17 pm [[And succeeding. Rapidly.]] FakeProwl 5:17 pm Extremely. It's a—a rapid addiction. ItsyBitsySpyers 5:19 pm *Soundwave tries not to huff too harshly at the "gods don't make mistakes" line.*

*He nods at Prowl's assessment.* [[It reminds him of someone he knows, in an odd way.]] FakeProwl 5:20 pm Oh? ItsyBitsySpyers 5:23 pm [[Mm, yes. A somewhat promising mech manipulated into an addiction to someone who now refuses to acknowledge their existence. He has seen them drop into despair in that being's absence. It is unpleasant to watch.]] FakeProwl 5:24 pm ... To what end? Were they someone's enemy? ItsyBitsySpyers 5:26 pm [[Nothing so important. He doesn't know for certain, but he believes the one who is now absent simply wanted a toy. Something to break and discard and laugh at when it limped back.]] [[That part is probably irrelevant to Odo's situation. The utter distraction and addiction is what reminded him of it.]] FakeProwl 5:28 pm ... Disgusting. The emotional addict—anyone I might know? ItsyBitsySpyers 5:29 pm [[Not that he knows of.]] ItsyBitsySpyers 5:31 pm [[Well done with the message.]] FakeProwl 5:32 pm Hm. I'd try to find a therapist for them, but all the ones I know are either terrible or retired. ItsyBitsySpyers 5:32 pm [[As are the ones he's passed by.]] FakeProwl 5:33 pm ... Pity. FakeProwl 5:34 pm Well. If their manipulator comes back to reclaim their toy—it might be nice if you blocked their attempts at contact. FakeProwl 5:35 pm *mumbles* What blatant misuse of his troops. FakeProwl 5:37 pm ... Well, that's not going to help their cause. ItsyBitsySpyers 5:37 pm [[He's made past efforts.]] *Folds his hands.* [[But yes. He'll try again, if he hears of it in time.]] FakeProwl 5:38 pm Kira should have let Dumber drag Ziyal away, Ziyal could have made an excellent spy with a direct link to Gold Docket. ItsyBitsySpyers 5:38 pm *Soundwave trembles a bit. Dumber. Oh, that's lovely. He'll let that one stand.* [[Her temper does get the better of her at times.]] FakeProwl 5:39 pm It certainly does. ItsyBitsySpyers 5:40 pm [[That said, he thinks Ziyal is too naive to do well as a spy.]] FakeProwl 5:40 pm True, but I think she's learning better. ItsyBitsySpyers 5:41 pm (("my pistons may be rusty but my hearing is sharp as ever")) [[It *would* be helpful.]] FakeProwl 5:44 pm Odo's still questioning her a little bit. ItsyBitsySpyers 5:45 pm *Nod nod.* FakeProwl 5:47 pm *Hope for the best, expect the worst. Prowl's afraid he would get along very well with Garak.* ItsyBitsySpyers 5:48 pm *What's there to be afraid of?* FakeProwl 5:48 pm *He seems /absolutely exhausting/ to be around.* ItsyBitsySpyers 5:53 pm ((u good?)) FakeProwl 5:54 pm ((im good)) ItsyBitsySpyers 5:54 pm {{S6E6 Sacrifice of Angels}} ItsyBitsySpyers 5:57 pm *Oh, he doesn't know. He could stand the occasional lunch now and then with someone with his own interests, as long as they didn't try to steal his position.* ItsyBitsySpyers 6:02 pm [[This despite his original attempt to kill her upon recovery from the planet she and her mother were stranded on.]] FakeProwl 6:02 pm As though "holding them for questioning" isn't the most transparent euphemism imaginable. Did he? Hmph. Unsurprising. ItsyBitsySpyers 6:04 pm [[Of course he did. He already had a family, and the former Prefect mating with a Bajoran? Two social strikes. She is close to Kira because Kira protected her.]] FakeProwl 6:07 pm *immediately tenses up at the word "anhedonic."* *deliberately forces avatar back to neutral.* ItsyBitsySpyers 6:08 pm *Corner of the optics glance and back to the screen. He's not going to pry, but he will note.* FakeProwl 6:10 pm He really does believe he was protecting and liberating Bajor. *shakes head.* I wasn't sure if that was something he told himself or something he told other people. But if he's sharing the same story with his allies... FakeProwl 6:12 pm ... Usually I would be intensely concerned about someone who allows love for a single person to completely dominate his personality, life, morality, and decisions. I'll make an exception for Odo because it might be the only thing left that can drag him out of this. ItsyBitsySpyers 6:14 pm *Wonders if Prowl is intensely concerned about Tarantulas. Wonders if he should ask that. Decides it's not his place to poke at that and nods again.*

[[Taking what they can get, at this point.]] FakeProwl 6:16 pm ... That was a very elaborate distraction. ItsyBitsySpyers 6:17 pm [[In a bad way or an impressive way?]] FakeProwl 6:17 pm In an unexpected and thus amusing way. ItsyBitsySpyers 6:18 pm [[Hm. Quark hasn't killed anyone before, he thinks.]] FakeProwl 6:18 pm I think you're right. FakeProwl 6:19 pm Please, PLEASE go help them. This is your shot, Odo. FakeProwl 6:21 pm ... If the Link is "paradise," that's all the more reason not to be part of it. Why waste time in a place that's already perfect when there's so much on the outside that still needs help? ItsyBitsySpyers 6:22 pm *Another glance.* [[You never consider retiring some day?]] *And there go all the mines.* FakeProwl 6:23 pm Doing what? ItsyBitsySpyers 6:24 pm [[He doesn't know. He thought you would, if you ever consider it.]] FakeProwl 6:24 pm No, I mean—I never considered doing /what/ someday? ItsyBitsySpyers 6:25 pm [[The idea of finding some place perfect to settle and be comfortable with all that you want at hand in your waning vorns. It is a fascinating alien concept. He thought you would be familiar with it from your travels.]] ItsyBitsySpyers 6:27 pm [[He tried it, himself. It turned out he wasn't very good at it.]] *Huff.* [[Now he is here.]] FakeProwl 6:27 pm ... Vaguely. Distantly. It's a concept that applies only to things that can die of old age. FakeProwl 6:30 pm ((i love how the Founder just constantly gives off the vibe of a slightly cross grandma)) ItsyBitsySpyers 6:31 pm *Nod. It was a tempting thing, but the thought of having nothing but leisure time for millions and millions of years... no, thank you.*

[[That was part of his reasoning for stopping. [][][]Why waste time - when there's so much on the outside that still needs help?[][][] ]] FakeProwl 6:31 pm *Nods at screen.* Useful gods they've got next door. ItsyBitsySpyers 6:32 pm [[Quite.]] FakeProwl 6:37 pm ... This probably isn't the message I should be taking from this, but what I'm getting is "give Megatron an offspring; kill it in front of him. Prevent a lot of unnecessary conquering and genocide." FakeProwl 6:38 pm ... Although if we're going to be traveling into the past to give and take a sparkling from him it might be easier to just kill him outright. ItsyBitsySpyers 6:39 pm [[Perhaps it isn't. He is not interested in that solution, himself.]] *Something of a silence.* [[But he has watched for timelines that could tell him if it is true.]] [[That is not the end of the story, though. We must summarize a few things and carry on.]] FakeProwl 6:40 pm No, it didn't seem like the end. Go on, then. ItsyBitsySpyers 6:41 pm [[Damar deeply regrets murdering Ziyal. He replaces Dukat, but cannot stand up to the Dominion's leaders and swiftly becomes the puppet connecting them to the Cardassian people.]]

[[Bashir and others believe surrendering now and rebelling later will involve less loss of life than continuing the war. The proposal's denied and Bashir's persuaded to change his mind. The others try to give classified information to the enemy, but he stops them, insisting that the course of history may yet be changed in their favor.]] ItsyBitsySpyers 6:42 pm {{S6E11 Waltz}} FakeProwl 6:43 pm All right. Let's go. FakeProwl 6:47 pm ... Hm. Surrendering now /will/ lead to less /immediate/ loss of life, at the cost of sustained gradual loss of life that might soon total far greater than would have been lost during the war. And it's much harder to liberate a tightly-held colony than it is to maintain an empire's freedom. ((i love it when actors do the "pretend the ship's been hit" jiggle dance)) ItsyBitsySpyers 6:48 pm ((tbh so do i, thinking of them trying to do that with the straight faces and all)) FakeProwl 6:49 pm ((dukat's was impressive, with the shaky knees)) FakeProwl 6:51 pm Kira and Odo are walking around together again. Is their relationship recovering or is it only business? ItsyBitsySpyers 6:52 pm ((agreed!))

[[Mm. One of the tapes he skipped took Bashir and Dax to an alien planet. The entire population was infected with an engineered fatal plague the Dominion unleashed on them for resisting. There were no possible cures; all infected were doomed. Bashir did manage to make a vaccine that would protect the offspring they produced, but that was all.]]

[[With that in mind... your second comment, the one regarding liberating tightly-held colonies? He is inclined to agree.]] [[Their relationship is slowly recovering, and will continue to do so for the next half a year.]]

[[And now: Sisko wakes up in a cavern. His only company is Dukat, who's hallucinating familiar figures. Dukat lies about the broken signal transmitter, insists they're "old friends", and repeatedly claims to be a decent person. Things are about to come to a head.]] ItsyBitsySpyers 7:01 pm ((it doesn't come across well in that delivery but the line is intended to be sarcasm)) FakeProwl 7:02 pm ... All this talk about inherent superiority, about how the victims should have accepted their inferiority, about how he should have killed them. Gold Docket sounds exactly like... *Grimace.* I was going to say a Decepticon. But, no. He just sounds like a Cybertronian. ItsyBitsySpyers 7:03 pm *Helm tilt.* [[Autobots too?]] FakeProwl 7:05 pm The Autobots were too busy stopping the Decepticons to do anything else. And—for now, at least, while the memories are fresh—I think there are too many of them who are determined to /not/ be like the Decepticons to do anything they did. But, the memories are going to fade. And the proud, glorious Cybertronian people are going to remember that they're /inherently better/ than all the foolish, short-lived little organics of the galaxy. ItsyBitsySpyers 7:07 pm [[Unless they're taught otherwise.]] FakeProwl 7:07 pm *SNORT.* Yeah. Sure. *Nods at the screen.* Who do you think could teach Gold Docket otherwise? We're a whole race of Gold Dockets. ItsyBitsySpyers 7:08 pm [[Us as well?]] FakeProwl 7:08 pm Define the scope of "us." ItsyBitsySpyers 7:09 pm [[There are only two of us on this couch.]] FakeProwl 7:10 pm I don't know enough about how you feel about organics. I'd like to think /I've/ learned better. But I don't know what I'm still carrying. ItsyBitsySpyers 7:11 pm [[Do you think yourself capable of continuing to learn? Of wanting to learn?]] FakeProwl 7:12 pm I try to be. FakeProwl 7:14 pm Are you going to try to tell me that other Cybertronians are capable of learning, too? Don't bother—you and I both know full well that most don't WANT to. When they do learn a lesson it's an accident and a great shock to everyone involved. ItsyBitsySpyers 7:24 pm [[We are both good at arranging accidents.]] *Quiet puff.* [[He does think we can become better as a whole than we have been. You know who he was, and you yourself have arrived here despite starting out in the depths of Functionism and mechanical superiority.]]

[[He doesn't know how to reach others yet, but he is looking, and he will keep looking. If you never feel as though it's possible for you to do that, then... that is your mind. But it does not change his.]] FakeProwl 7:24 pm *... Prowl made a mistake by saying anything. The show stopped.* ItsyBitsySpyers 7:24 pm *He didn't make a mistake; there's just summaries coming and they were on a topic.* FakeProwl 7:26 pm ... Mm. *Gestures at screen.* Let's just... go on. ItsyBitsySpyers 7:26 pm [[As you wish. He must explain passing events we do not have time to cover, though.]] FakeProwl 7:26 pm *Nods.* ItsyBitsySpyers 7:27 pm [[General events.]]

[[More crew members face unpleasant wartime scenarios. Chief O'Brien chooses between completing an infiltration mission and saving the enemy friend he made. Worf is faced with winning a battle or saving his spouse. Kira, who despises collaborators, learns that her mother became one of Dukat's "companions" to save her family. Bashir's life is turned upside-down by an undocumented Federation spy organization, Section 31. Sisko and Garak conspire and lie to drag the Romulans into joining the war, as you may recall once seeing.]] ItsyBitsySpyers 7:29 pm [[During a lull, a self-aware hologram musician advises Odo on his interest in Kira and helps him gain confidence. Odo confesses his feelings to what he thinks is a hologram of Kira and they enter a relationship when the truth is revealed.]] FakeProwl 7:29 pm ... I don't recall seeing something like that, but I'll take your word for it. ItsyBitsySpyers 7:31 pm [[...No, you weren't there, were you? The others were. That's right. Hmm. He'll have to send you that some time.]] [[Never mind. You know now.]] FakeProwl 7:31 pm Indeed. ItsyBitsySpyers 7:32 pm [[He apologizes. He's still somewhat weary from the weekend, and movie nights do blend now and then if he isn't specifically reviewing the details.]]

[[Lastly, Sisko is forced to fight pah-wraiths - enemies of the wormhole aliens - even though it may kill him and his son. Jealous of his greater faith and the gods' attention to him, Kai Winn ruins his victory under the guise of saving them. Sisko and his son live, but the pah-wraiths escape.]] ((*casually blames muse's DJing for the mun's error*)) [[Now we may continue.]] FakeProwl 7:34 pm ((blaming your own mistakes on your muse is Good Writing.)) ItsyBitsySpyers 7:35 pm {{S7E6 Treachery, Faith, and the Great River}} FakeProwl 7:38 pm ... I don't trust this defection. ItsyBitsySpyers 7:39 pm [[The Vorta *have* historically been slippery and sneaky.]] FakeProwl 7:40 pm Indeed. ((WAIT THAT'S JEFFREY COMBS)) ((I DIDN'T REALIZE. BUT I CAN HEAR IT NOW)) ItsyBitsySpyers 7:40 pm ((LMAO YES that's why i've been making jokes about ratchet)) FakeProwl 7:41 pm ((AND NOW I'M NOT GOING TO BE ABLE TO STOP HEARING PRISSY RATCHET)) ItsyBitsySpyers 7:42 pm (( 😄 )) FakeProwl 7:42 pm It is true that he's culturally and perhaps genetically altered to view Odo as a god. ItsyBitsySpyers 7:44 pm *Nod.* [[Quick way to ensure loyalty.]] FakeProwl 7:44 pm But the other Founders may still have convinced him to regard Odo as a fallen god, and thus to spy on him. ... But, I can be convinced. ItsyBitsySpyers 7:45 pm [[Heh.]] FakeProwl 7:47 pm ... He's saying all the right things. Live in peace with the solids, et cetera. And that's suspicious. FakeProwl 7:50 pm I hope he's sincere, though. He could be a great asset. ItsyBitsySpyers 7:51 pm [[One of the best they could ask for.]] FakeProwl 7:54 pm Well, he's already taught the Federation the weak point of a Jem'Hadar ship. ItsyBitsySpyers 7:55 pm [[If he *was* a planted spy, letting him talk about things like that would be a serious error in judgment.]] FakeProwl 7:56 pm Indeed. ((oh my god. that's the worst way i've ever seen a pizza be eaten.)) ItsyBitsySpyers 7:57 pm ((it's adorable tho)) FakeProwl 7:58 pm ((it is)) FakeProwl 8:01 pm *"You have an opportunity to rectify the mistakes your people have made." Sits up and leans forward.* *An intriguing possibility. ... But one that requires the rest of the race to die off first.* ItsyBitsySpyers 8:05 pm *May he never have to hide in an ice blob.* FakeProwl 8:09 pm ... Time for the regular movie night, isn't it? ItsyBitsySpyers 8:10 pm [[Yes. But he is available tomorrow night. We can do our best to wrap it up then.]] FakeProwl 8:10 pm I don't suppose we can convince the regular moviegoers to watch the amazing adventures of Odo? *wry smile* ItsyBitsySpyers 8:11 pm [[Not without as much context as he's given you. Though he might be convinced to play more of these tales in general, soon.]] [[For now, he must have a few moments to prepare. You're welcome to explore outside, if you would like to see the canyon while he is busy.]] FakeProwl 8:13 pm If you don't need my help, I'll wait here. *He'll supervise.* ItsyBitsySpyers 8:13 pm [[Very well.]]

*And Soundwave will set about doing just that.*

#slenderwave #chat

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bobbydillenger · 7 years

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Awakening

Anxiety and depression can be crippling and in the worst case scenarios even spiral to the depths of suicide so it comes as no surprise that those facing them see the avoidance of such as a mere matter of self preservation - as primitive as instincts to eat, sleep and keep sheltered. As someone who has personal experience with depression the best I've can arrange words to describe it are inspired by and cited below (reworded) by pulitzer prized novelist Donna Tartt. Depression doesn't even begin to describe what even Shakespeare himself could not. Anyone who has felt heartbreak knows that even excruciating physical pains are nothing compared to those of the soul. If Byron, Proust and Shakespeare fail to do it justice then why even try? Because I, like all writers have the same goal - to describe a universal human experience in my own words. I use other great writers as inspiration with hopes it might enrich even one reader's life in a way no other writer has been able to do. My two biggest influences, David Foster Wallace and Donna Tartt have touched my soul and enriched my life in ways no other writer could and consequently become my most kindred spirits THE DARKNESS It dawns unexpectedly as an unendurable sopping black curtain of horror. A psychic darkness like nothing you've ever dreamed. It is an icy plunge encompassing sorrows and revulsion far beyond the personal: a sick, drenching nausea at all humanity and human endeavors from the dawn of time. The writhing loathsomeness of the entire biological order. Old age, sickness, suffering, death. No escape for anyone. Even the young, the famous, the beautiful are like soft fruit about to spoil. And yet somehow people keep breeding and popping out new fodder for the grave, to suffer...like it was some kind of redemptive, or good, or even somehow morally admirable thing: dragging more innocent, sentient creatures into this lose - lose game. Squirming babies and plodding, complacent, hormone drugged moms. Oh, isn't he cute? Awwwww. Kids shouting and skidding in the playground with no idea what future Hells await them: boring jobs and ruinous mortgages and bad marriages and hair loss and hip replacements and lonely cups of coffee in an empty house and a colonoscopy bag at the hospital. -DT You begin to hate yourself for the same reasons you are unique and interesting and beautiful. You just wish you were like everyone else, like those that seem satisfied with the thin decorative glaze and artful stage lighting that, sometimes, make the bedrock atrocity of the human predicament look somewhat more mysterious or less abhorrent. The mornings are the worst because the new day brings only more angst and fear, you can't find the same hypnotized complacency that others do in meaningless chores and busy work. Cursing yourself, cursing God for keeping you from enjoying the things others find so fascinating. You begin to curse others too, you curse them because they are enjoying the life you can't. Their time, which is the true equalizer - the one thing you may have more of than others regardless of class, money or social standing - is now literally worth more than yours. Why? Because at least someone is enjoying their time. People gamble and golf and plant gardens and trade stocks and make love and buy new cars and practice yoga and work and pray and redecorate their homes and get worked-up over the news and jog and fuss over the children and gossip about their neighbors and pore over restaurant reviews and support political candidates and dine and travel and distract themselves with all kinds of gadgets and devices, flooding themselves with information and texts and communication and entertainment from every direction to try and make themselves forget it: where we are, what we are. But in a strong light there is no good spin you can put on it. It is rotten, top to bottom. -DT Putting your time in at the office: dutifully spawning your 2.5, smiling politely at your retirement party; then chewing on your bed sheet and choking on your canned peaches at the nursing home. It was better to have never been born, to never have wanted anything, to have never hoped for anything. All this mental thrashing and tossing gets mixed up with recurring images, PTSD, half dreams, nightmares, regret, self pity and bad decisions self perpetuating it all. You become callous, hollow to the core, fragile, desperate and scared to death of some unknown impending doom. Maybe those of us who experience depression and anxiety were born more in-tune and emotionally robust. I imagine we are much less easily distracted from the realities of the biological trap and the inevitably of humanity’s rampant, relentless human suffering. The more clearly we see it, the more cynical our worldviews become and the more we seek an escape. This feeling, perhaps just a phase, perhaps a lifelong trap, is an unfortunate disposition that is distinctly dark, dysphoric and anhedonic. For some, sadly, it grows into a complete inability to enjoy life or feel anything for that matter, which is an almost peaceful void in comparison to the next stage - a complete inability to endure life - to which the only escape is the eternal. Luckily there is a remedy, but it is a gift given without prejudice. The gift can best be described as an awakening. It is either written in our destiny or not, we do not chose our paths. I'm not sure where it comes from or who chooses the intended recipients, but it manifests as nothing but a belief. Not a truth nor explanation, just an unquestionable knowledge that love is the whole meaning, nothing more, nothing less. A telltale sign of those given the gift is an almost visible glow, a palpable charisma that makes them magnetically comfortable to be with. The good news for those who suffer from depression is that same emotional pain you have endured is exactly what will make the gift a possibility. This awakening is far from true enlightenment or Nirvana but rather a freedom from seeking. Those emerging from the darkness no longer need the mindless distractions that occupy the other people. They can finally begin to find enjoyment in the things money can't buy. They don't need new cars or Paris or a yacht or Las Vegas because they have sunsets, the ocean and a child's laughter. In conclusion, my best metaphor for it..the realization you are actually wearing the pair of glasses you were frantically looking for the past 20 minutes. Joy without pain, hope without despair etc. To anyone out there struggling with depression or feeling hopeless, there is a light at the end of the tunnel, you will find the happiness and meaning you seek, just don't give up, know you are not alone and don't forget to look right in front of your face.

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awesomeonmyown7 · 7 years

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Initial Evaluation: Z.D.M 21/F (MDD) - May 5, 2017

This is the case of Z.D.M. a 21 year old female diagnosed with possible MDD.

Subjective: I. Cheif Complaint: acc to the client “Nagpakatanga ako. At nagpadala sa emotion.”

II. Goals: acc to the client “Ayoko na. Tama na. Magmomove on na ko.”

III. HPI 1 month PTIE, client broke up with her bestfriend 2 weeks PTIE, client had a nervous breakdown because of jelousy and thus developed gerd 1 day PTIE, client was mad af and crying like shit

IV. Past Medical Hx Hospitalized for dengue and Gastroesophageal Reflux Disease

V. Personal Social Hx Too long to mention

VI. Performance Patterns A. Roles: Bestfriend, daughter, student B. Habits: Impoverished Habit of letting self get hurt everytime C. Routines: URGENTLY NEEDS CHANGING

OBJECTIVE: A. Mental Status Examination i. General Description - the evaluation was conducted in the client’s brain at several intervals Apperance - dishriveled hair, untidy look, untied shoelaces, anhedonic, unmotivated Attitudes towards others - client would smile and chat but cannot make eye contact, occassionally withdrawn

ii. Mood and Affect Mood - Labile Affect - Inappropriate

iii. Speech Quality - full of thought Quantity - sometimes impoverished sometimes has a lot to saaay Rate - Fast. Mad. Hurt. Crying. In pain

iv. Perception Illusions - negative. Pero umasa at nagtiwala sa hangin Hallucinations - negative. Kasi may social support siya

v. Thought content and Mental Trends Thought process - over thinking, flight of ideas, rationalization Thought content - delusion of persecution, delusion of hope na may friendship pa, delusion of believing it doesnt hurt, paranoia, denial, tendencies for suicidal ideations

vi. Sensorium and Cognition Orientation - Ox2. Oriented to place & person, BUT NOT TO THE SITUATION AND THE TIME Conciousness - alive but barely breathing Concentration and Attention - meh Memory - Good. Remembers everything…even the ones she shouldnt. Abstract thought - Good. Makes metaphors. Visuospatial ability - Good. Reading and writting - genius. Lol jk General Information - KNOWS TOO MUCH

vii.Insight Intellectual - good True emotional - not so good ERGO: IMPAIRED

viii. Judgement Social - Very Poor. Gives people too much benefit of the doubt Test - Okay? ERGO: IMPAIRED

ix. Work behaviors Attention Span - Fair. Needs prodding Concentration - Fair. Needs prodding Impulse control - Poor. SO VERY POOR. Frustration Tolerance - ALSO EXTREMELY POOR Problem Solving - genius at everything except self problems Judgement - Poor af. Following Instructions - Fair. BUT NEEDS EXTREME PRODDING.

x. Attitudes towards self Self-esteem: POOR AF Self-confidence: POOR AF

xi. Attitudes towards others Can be too nice but you know, she needs saving

Recommend: Beck depression inventory and azima as needed.

B. Functional Assessment ADL - poor grooming and eating IADL - poor health management and maintenance Education - fluctuating educational performance due to emotional instability Social Participation - selective with who to talk to Leisure - cannot find anything satisfying enough Work - meh Play - in need of fun & company Sleep and Rest - heavily affected because of insomia and thoughts

OPA Table…cannot fit in this post ahahuhu

ASSESSMENT i. S&W = lets just say she’s high func but has a hell load of issues.

ii. Prioritized Problem List 1. Problems in ADLs specifically Eating and Grooming 2. Problems in IADLs specifically Health Management and Maintenance 3. Problems in Sleep participation 4. Problems in Educational Participation 5. Problems in Leisure Participation 6. Problems in Social Participation

iii. Prognosis: Guarded. If she can follow and listen to people’s advice then she’ll be okay. If she cannot..then she will destroy herself

iv.OT Diagnosis: Client experiences problems in majority of her occupations due to problems in emotional regulation, poor motivation and poor work behaviors, disrupted routines as evidenced by having poor insight, poor judgement, irrational beliefs, having loss of apetite, getting easily distracted, being unable to focus, fluctuating performance in tasks, not wanting to do anything for herself, inability to move on, overthinking, marked displeasure, withdrawn behavior and suicidal ideations secondary to depression.

PLAN LTG1: In 1 week of OT sessions, Client will be able to independently engage ADL participation specifically eating. STG1: Client will be able to independently identify atleast 10 viands of food she finds apetizing given a table top activity in 1 OT session STG2: Client will be able to eat 5 spoonfools of food independently given cognitive behavioral techniques in 1 OT session STG3: Client will be able to eat a whole meal independently given cognitive behavioral techniques in 5 OT sessions

POA: Prep - client will be given cognitive behavioral techniques to redirect her thoughts & SMRTs Purp - client will be asked to think of things she likes or that make her happy; client will create a “happy schedule” which includes when she will do things that make her happy Occ based - client will be able to state and write/draw things she likes to eat in a peice of paper; client will be able to eat in an eating activity TUS: Kind Firmness - Matter of Fact TUG: Topical. Good friends, good company EMT: REMOVE POTENTIAL TRIGGERS

LTG2: Client will be able to independently improve ADL participation specifically grooming in 1 week of OT sessions STG1: Client will be able to come to school with her hair brushed independently in 4 OT sessions given cognitive behavioral techniques STG2: Client will be able to tie her shoes and tidy her clothes idependently in 3 OT sessions.

LTG3: Client will be able to independently improve IADL participation specifically health management and maintenance in 1 week of OT sessions STG1: Client will drink her medicines independently on time given cognitive behavioral therapy in 3 OT sessions STG2: In 4 OT sessions, client will have independently developed and follow a daily routine which involves eating on time given cognitive behavioral therapy.

LTG4: Client will be able to engage in sleep participation independently in 3 days of OT sessions. STG1: Given Cognitive behavioral techniques and SMRTs, client will be able to sleep and wake up without thinking of traumatic events in 3 OT sessions

LTG5: Client will have independently improved educational participation in 1 week of OT sessions STG1: Client will be able to focus and accomplish a given task independently in the specified time given cognitive behavioral techniques and SMRTs in 2 OT sessions STG2: Client will be able to produce quality output in 1 OT session given cognitive behavioral techniques and SMRTs STG3: Client will be able to get high grades on her written and practical exams in 4 OT sessions given cognitive behavioral techniques and SMRTs

LTG6: In 1 week of OT sessions, client will be able to engage in social participation with peers and family independently. STG1: Client will be able to state 10 things she finds purposeful in herself and in others given cognitive behavioral therapy in 1 OT session STG2: Client will be able to stop devalueing herself and stop overthinking independently for at least 1 hour in 2 OT session given cognitive behavioral therapy STG3: Client will be able to get through the day without devaluing herself and overthinking and talk to atleast 5 people independently in 4 OT sessions given cognitive behavioral therapy

LTG7: Client will be able to engage in leisure tasks independently in 1 week of OT sessions STG1: Client will be able to state 10 things she likes to do independently given cognitive behavioral therapy in 3 OT sessions. STG2: Client will be able to engage in atleast 3 leisure activities independently given cognitive behavioral therapy in 3 OT sessions. STG3: Client will be able to find something thankful about from the day, everyday given cognitive behavioral therapy and SMRTs in 1 OT session

Recommendations: Good & REAL friends, Good company, healthy environments.

this is my case. This is what I need to do. This is the first phase of the happiness project. And I thank everyone who is constantly being there for me. I owe you guys. -z.

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o5oflies · 6 years

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Dear Overseer, wow thanks for the reply! Im going to honest, Im not JB Gill though I think his music is nice. And i guess i should have said what the gift was... it was so cute. he came into rec this morning all covered in blood and he handed me a couple of teeth before winking at me and walking away like a cool guy. I think your right and he feels positively about me... i just gotta think of a proper next move to make. By the way, are you ok? Your earlier posts sounded... sad

I always reply to matters involving people important to someone! Especially when they stop thinking “get out of my workspace” is appropriate flirtation techniques.

Oh, I know you’re not, I always know! I know everything. Everything I need to. Including that no celebrities would be contacting me. If they were, I’d be more concerned, really! Especially if they were addressing me like that. Unless you’re Jack Black, everyone knows he’s anomalous.

Blood and teeth, huh? Well, I sure hope they came from someone who really, truly deserved it, or we might have some little differences we will need to discuss. In person. Non-negotiable.

But anyway! Since that seems to be your thing, or maybe it’s his thing and he wanted to share it with you, well, a good opener can be thanking him for it. From there, you can take the conversation where it needs to go. Well, hopefully. Doing it can be hard. But, again, being imperfect or unskilled isn’t necessarily a negative point, in these things.

Maybe giving him a gift in return along with asking him to accompany you somewhere. If you’re anxious, make it somewhere low stakes, and see how that goes? You can always plan to do more things if it’s going well, but if it doesn’t go ell, you can always end it without doing the extra. No pressure, see?

As far as the sad goes? Well, O5-11 is many things. Contains multitudes. Sad, happy, angry, afraid, euphoric, apathetic, anhedonic, irate, morose, grieving, celebrating, shocked, surprised, in love, in hate, philophobic, powerful. It doesn’t really matter which is true, now does it? Could be all, a few, most, none, or only one, and I’d be the only one who knew. If I am, indeed, the same O5-11. If I indeed know the truth at all. If those posts were true. If I have emotions.

I am alright, no matter what the case is. Believe it or not, I take care of myself. Every O5-11 does, or we kick them out. If I wasn’t okay, I would be doing something to fix that. If I wasn’t okay, I couldn’t do anything at all. There is no fixing it. No words. They don’t exist. I have all the words. I have spoken to someone. They had good advice. They were asleep. No one gets what self care for me looks like. Everyone helps me with it.

You, little buddy, aren’t responsible for me or my well being. I know very, very well how to handle these things. I’ve never had this issue before. I’ve had it my whole life. I never thought of it as an issue. It’s always hurt me. It’s never hurt me. It aids me. It doesn’t exist. Those posts were a distraction.

I’m happy and I like myself. I love everyone. That’s all that matters.

I will have the help I need, when I need it. Promise.

#hearts full of light #feel the rain #hiding behind a mask #a game of question and response #a poet without words

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unillustratedadventures · 4 years

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Bipolar Disorders: Additional Information (per DSM-5)

In this post, I shall only be covering bipolar I, bipolar II, and cyclothymic disorder, as discussed in DSM-5 (p. 123–9). For the full definitions (i.e. full diagnostic criteria) of these disorders, please see my previous post.

Here, I shall characterise the disorders in the following, simpler ways. Roughly-speaking, an individual has a…

bipolar disorder (in general) just in case she has been impaired or dysfunctional due to a mood disturbance involving manic or hypomanic symptoms;

bipolar I (specifically) just in case she has had a full manic episode;

bipolar II (specifically) just in case she has had both a full hypomanic episode and a full major depressive episode (but no manic episode);

and

cyclothymic disorder (specifically) just in case, during a substantial period of time, she has experienced both manic/hypomanic and major depressive symptoms, almost always having one or the other, in a manner that has caused impairment or dysfunction, without ever actually having a full manic, hypomanic, or major depressive episode.

Also recall that, roughly-speaking:

manic/hypomanic symptoms are specific possible indications of having an excessive mood characterised by elevated feelings and/or irritability as well as by increased energy or activity, which in a previous post I labelled as inflated self-esteem, decreased need for sleep, increased speech, racing thoughts, distractibility, increased outward activity, and recklessness;

a full manic episode is just an excessive state of elevated/irritable mood with increased energy/activity that involves at least three of the above symptoms and causes acute clinically significant impairment or dysfunction (as reflected by particular features/outcomes);

a full hypomanic episode is just an excessive state of elevated/irritable mood with increased energy/activity that involves at least three of the above symptoms without causing acute clinically significant impairment or dysfunction (as reflected by the same features/outcomes);

major depressive symptoms are specific possible indications of having an excessive mood characterised by negative feelings and/or anhedonia (a reduced ability to experience and anticipate pleasure and positive feelings) which in a previous post I labelled as persisting negative mood, loss of interest/pleasure, appetite disturbance, sleep disturbance, psychomotor disturbance, fatigue, negative self-appraisal, cognitive-executive disturbance, and suicidal ideation;

a full major depressive episode is just an excessive state of sadness-related and/or anhedonic mood that involves at least five of the above symptoms, necessarily including persisting negative mood or loss of interest/pleasure, which causes significant impairment or dysfunction.

Diagnostic Features of Bipolar Disorders

For diagnostic features pertaining to manic/hypomanic episodes in general (as well as a discussion of the seven possible symptoms of mania/hypomania), please see this post on mania/hypomania.

Bipolar II and Specifics of Hypomania

Since it is true by definition that just a single manic episode is sufficient for diagnosing bipolar I, episodes of elevated//irritable mood must be only hypomanic in the course of bipolar II disorder. Roughly-speaking, hypomanic episodes are states of mood that are abnormal (e.g. in their strength, persistence, or reactivity) without being so extreme that they lead to further clinically significant issues. In particular, if an episode of elevated/irritable mood involves psychosis (i.e. delusions or hallucinations), results in marked impairment in social or occupational functioning, or requires hospitalisation to prevent harm to self or others (e.g. financial losses, illegal activities, loss of employment, or self-injurious behaviour), then it qualifies as an episode of mania. However, if it lacks any of these markers of clinical significance, but involves sufficiently many indicators of excess (i.e. inflated self-esteem, decreased need for sleep, increased speech, racing thoughts, distractibility, increased outward activity, and recklessness) then it qualifies as an episode of hypomania.

A hypomanic episode should not be confused with the several days of euthymia (i.e. baseline or normal mood) and restored energy/activity that often follows remission of a major depressive episode.

Individuals with bipolar II typically present to a clinician during a major depressive episode, and are unlikely to complain initially of hypomania. Usually, the hypomanic episodes themselves do not cause noticeable impairment. Instead, the impairment tends to result from the major depressive episodes, or from a persistent pattern of unpredictable mood changes and fluctuating, unreliable interpersonal or occupational functioning. Individuals with bipolar II might not view the hypomanic episodes as pathological or disadvantageous, although others are often troubled by the individual’s erratic behaviour.

Typical presentations of bipolar I involve all three of the recognised forms of clinically significant mood—i.e. mania, hypomania, and major depression—even though only an episode of mania is strictly necessary for diagnosing bipolar I. However, while it is typical that bipolar I individuals occasionally have episodes of major depression, individuals with bipolar II tend to have recurrent major depressive episodes that are more frequent and lengthier than those occurring in the course of bipolar I.

Despite the substantial differences in duration and severity between manic and hypomanic episodes, bipolar II is not a “milder form” of bipolar I. Compared with bipolar I individuals, individuals with bipolar II tend to have greater chronicity of illness and spend, on average, more time in the depressive phase of their illness, which can be severe and/or disabling.

Mixed symptoms—i.e. depressive symptoms in a hypomanic episode or hypomanic symptoms in a depressive episode—are common in individuals with bipolar II, and are overrepresented in females. Hypomania with depressive symptoms is particularly overrepresented in bipolar females. Individuals experiencing hypomania with mixed features often do not construe their symptoms as predominantly hypomanic (i.e. predominantly energised or elevated/irritable), but instead as predominantly depressive, e.g. as a predominantly negative or pleasure-lacking mood that just so happens to cooccur with increased energy or irritability.

Specifics of Cyclothymia

In contrast to bipolar I and bipolar II, the essential feature of cyclothymic disorder is a chronic, fluctuating mood disturbance that involves numerous distinct periods of hypomanic symptoms and depressive symptoms, of insufficient number, severity, pervasiveness, or duration to meet full criteria for a hypomanic or major depressive episode.

If an individual diagnosed with cyclothymic disorder subsequently (i.e. after the initial two years in adults or one year in children or adolescents) experiences a major depressive, manic, or hypomanic episode, then the diagnosis changes to the appropriate disorder (e.g. MDD or bipolar I), and the cyclothymic disorder diagnosis is dropped.

Although some individuals may function particularly well during some of the hypomanic periods, over the prolonged course of the disorder, there must be clinically significant distress or impairment in social, occupational, or other important areas of functioning as a result of the mood disturbance. The impairment may develop as a result of prolonged periods of cyclical, often unpredictable mood changes (e.g. the individual may be regarded as temperamental, moody, unpredictable, inconsistent, or unreliable).

Associated Features Supporting Diagnosis

During a manic/hypomanic episode, individuals often do not perceive that they are ill or in need of treatment and vehemently resist efforts to be treated. Individuals may change their dress, makeup, or personal appearance to a more sexually suggestive or flamboyant style. Some perceive a sharper sense of smell, hearing, or vision. Gambling and antisocial behaviours may accompany the episode (especially in the case of full mania). Some manic/hypomanic individuals may become hostile and physically threatening to others—and, when delusional in the course of a fully manic episode, might even become physically assaultive or suicidal. The catastrophic consequences of a fully manic episode (e.g. involuntary hospitalisation, difficulties with the law, serious financial difficulties) often result from poor judgment, loss of insight, and hyperactivity. Bipolar II is often accompanied by more general impulsivity, which can contribute to suicide attempts and substance use disorders.

During mania/hypomania, the mood may shift very rapidly to anger or depression. Depressive symptoms may also occur during a continuing manic/hypomanic episode and, if they are present, may last anywhere from moments or hours to (more rarely) days.

There may be heightened levels of creativity in some individuals with a bipolar disorder. However, it is possible that the relationship is nonlinear; greater lifetime creative accomplishments have been associated with milder forms of bipolar disorder, and higher creativity tends to be found, on average, in the unaffected family members of bipolar individuals. An individual’s attachment to heightened creativity during hypomanic episodes can contribute to ambivalence about seeking treatment, or undermine adherence to treatment.

Development and Course: Bipolar I

In bipolar I, the mean age at onset of the first manic, hypomanic, or major depressive episode is approximately eighteen years.

More than 90% of individuals who have a manic episode go on to have recurrent mood episodes.

Approximately 60% of manic episodes occur immediately before a major depressive episode.

Individuals with bipolar I disorder who have multiple (four or more) mood episodes (major depressive, manic, or hypomanic) within a single year are specified as having bipolar I with rapid cycling.

Diagnosis in Children and the Elderly

Special considerations are necessary to detect the diagnosis in children. Since children of the same chronological age may be at different developmental stages, it is difficult to define with precision what is “normal” or “expected” at any given point. Therefore, each child should be judged according to his or her own baseline.

Onset of bipolar I can occur throughout the life cycle, with first onsets even possible in the 60s or 70s. However, in late mid-life or late life, onset of manic symptoms, e.g. sexual or social disinhibition, should first prompt consideration of medical conditions (e.g. frontotemporal neurocognitive disorder), and of substance ingestion or withdrawal.

Development and Course: Bipolar II

Although bipolar II can begin in late adolescence and throughout adulthood, average age at onset is the mid-20s, which is slightly later than for bipolar I but earlier than for MDD.

The number of lifetime mood episodes (both hypomanic and major depressive) tends to be higher for bipolar II than it is for either MDD or bipolar I. However, individuals with bipolar I are actually more likely to experience hypomanic symptoms than are individuals with bipolar II.

In the course of bipolar II, the interval between mood episodes tends to decrease as the individual ages (or, in other words, the intermediate periods of euthymia tend to shorten)

Most often, the illness begins with a depressive episode. In such a case, the condition is frequently not recognised as bipolar II until a hypomanic episode subsequently occurs; this happens in about 12% of individuals with an initial diagnosis of MDD. Anxiety, substance use, or eating disorders may also precede an official diagnosis, complicating the detection of bipolar II. Many individuals experience several episodes of major depression prior to the first recognised hypomanic episode.

While the hypomanic episode is the feature that defines bipolar II, the episodes of major depression are more enduring and disabling over time.

If an individual is initially diagnosed with MDD, once a hypomanic episode has occurred the diagnosis becomes bipolar II and never reverts to MDD (despite the predominance of major depression in bipolar II).

About 5%–15% of individuals with bipolar II will ultimately develop a manic episode, thereby changing their diagnosis to bipolar I regardless of subsequent course.

Approximately 5%–15% of individuals with bipolar II have had multiple (four or more) mood episodes of hypomania or major depression within the same year. Such individuals are specified as having bipolar II disorder with rapid cycling.

By definition, psychotic symptoms do not occur in hypomanic episodes, and therefore never occur alongside manic/hypomanic symptoms in bipolar II. Additionally, psychotic symptoms appear to less frequently occur within the major depressive episodes of bipolar II than they do within the major depressive episodes of bipolar I.

Switching from a depressive episode to a hypomanic episode (with or without mixed features) can occur in bipolar II, either spontaneously or due to pharmacological treatment for depression.

Diagnosis in Children and the Elderly

Diagnosing bipolar II in children is often a challenge, especially in those with irritability and hyperarousal that is non-episodic (i.e. lacks the well-demarcated periods of altered mood). Non-episodic irritability in youth is associated with an elevated risk for anxiety disorders and major depressive disorder in adulthood, but not bipolar disorder in adulthood. Persistently irritable youths have lower familial rates of bipolar disorder than do youths who have bipolar disorder. For a hypomanic episode to be diagnosed, the child’s symptoms must exceed what is expected in a given environment and culture for the child’s developmental stage.

Compared with adult onset, childhood or adolescent onset of bipolar II disorder may be associated with a more severe lifetime course.

The 3-year incidence rate of first-onset bipolar II in adults older than 60 years is 0.34%. However, distinguishing individuals older than 60 years with bipolar II disorder by late versus early age at onset does not appear to have any clinical utility.

Development and Course: Cyclothymic Disorder

Cyclothymic disorder usually begins in adolescence or early adult life and is sometimes considered to reflect a temperamental predisposition to bipolar I and bipolar II.

There is a 15%–50% risk that an individual with cyclothymic disorder will subsequently develop bipolar I or bipolar II.

Cyclothymic disorder usually has an insidious onset and a persistent/chronic course.

Diagnosis in Children and the Elderly

Among children with cyclothymic disorder, the mean age at onset of symptoms is 6.5 years of age.

Onset of persistent, fluctuating hypomanic and depressive symptoms later in adult life needs to be clearly differentiated from bipolar and related disorder due to another medical condition and depressive disorder due to another medical condition (e.g., multiple sclerosis), before the cyclothymic disorder diagnosis is assigned.

Risk and Prognostic Factors

Known Environmental Factors

Bipolar disorders are more common in high-income than in low-income countries (1.4 versus 0.7%).

Separated, divorced, and widowed individuals have higher rates of bipolar I than do individuals who are married or have never been married, but the direction of the association is unclear.

The risk of bipolar II tends to be highest among relatives of individuals who specifically have bipolar II, as opposed to relatives of individuals who have bipolar I or MDD.

Known Genetic and Physiological Factors

A family history of bipolar disorder is one of the strongest and most consistent risk factors for having a bipolar disorder. On average, there is a 10-fold increased risk of a bipolar disorder among adult relatives of individuals who have bipolar I or bipolar II. The magnitude of risk increases with the degree of kinship.

MDD, bipolar I, and bipolar II are all more common among first-degree biological relatives of individuals with cyclothymic disorder than in the general population. There may also be an increased risk of substance-related disorders among first-degree biological relatives of those with cyclothymic disorder.

Conversely, there is some evidence that cyclothymic disorder is also more common in the first-degree biological relatives of individuals who have bipolar I.

Schizophrenia and bipolar disorders (especially bipolar I) likely share a genetic origin, as reflected in their familial co-aggregation.

In addition to genetic vulnerabilities to bipolar disorders per se, there also may be genetic factors that influence the age of onset of a bipolar disorder.

In the course of a bipolar disorder, rapid-cycling patterns are associated with poorer prognosis.

If a bipolar I individual has a manic episode with psychotic features, subsequent manic episodes are more likely to have psychotic features.

Individuals with a bipolar disorder typically return to their euthymic baseline state between mood episodes (which, while still having signs of abnormal functioning, is normal for the individuals themselves in the absence of a mood episode). However, sometimes an individual will not fully return to euthymic baseline between mood episodes, and this is more common after mood episodes that have mood-incongruent psychotic features.

More education, fewer years of illness, and being married are each independently associated with functional recovery in individuals with a bipolar disorder, even when controlling for the diagnostic type of bipolar (i.e. bipolar I versus bipolar II), the presence of depressive symptoms, and the presence of psychiatric comorbidities.

In the course of bipolar II, returning to a previous level of social functioning is more likely for individuals of a younger age and with less severe depression. This suggests that prolonged illness with bipolar II has adverse effects on recovery.

Gender-Related Diagnostic Issues

Females with a bipolar disorder:

are more likely to have rapid cycling than males who have a bipolar disorder.

are more likely to have mixed mood episodes (i.e. mood episodes that combine both manic/hypomanic and depressive symptoms) than males who have a bipolar disorder.

have patterns of comorbidity that differ from those of males, including higher rates of lifetime eating disorders.

are, among those who specifically have bipolar I or bipolar II, more likely to have depressive symptoms than males who have bipolar I or bipolar II.

have a higher lifetime risk of comorbid alcohol use disorder than do males with a bipolar disorder, and a much greater likelihood of alcohol use disorder than females in the general population.

Whereas the gender ratio is equal for bipolar I, findings on gender differences in bipolar II are mixed, differing by type of sample (i.e. registry, community, or clinical) and by country of origin. There is little to no evidence of bipolar gender differences in non-clinical samples. However, some (but not all) clinical samples suggest that bipolar II is more common in females than in males, which might reflect gender differences in treatment seeking, or other factors.

Patterns of illness and comorbidity seem to differ by gender. Females are more likely than males to report hypomania with mixed depressive features and to present with a rapid cycling bipolar disorder.

Childbirth may be a specific trigger for a hypomanic episode, which can occur in 10%–20% of females in nonclinical populations, most typically in the early postpartum period. Distinguishing hypomania from the elated mood and reduced sleep that normally accompany the birth of a child can be challenging. Postpartum hypomania may foreshadow the onset of a depression that occurs in about half of females who experience postpartum “highs.” Accurate detection of bipolar II may help in establishing appropriate treatment of the depression, which, in turn, might reduce the risks of suicide and infanticide.

Suicide Risk

The lifetime risk of suicide in individuals with a bipolar disorder is estimated to be at least 15 times that of the general population. In fact, bipolar disorder may account for one quarter of all completed suicides. Greater risk for suicide attempts and completions is associated both with a past history of suicide attempts and with a higher proportion of days spent depressed in the previous year.

In relation to bipolar II specifically, approximately one third of bipolar II individuals report a lifetime history of suicide attempts.

Although the prevalence rates of lifetime attempted suicide appear to be similar in bipolar II and bipolar I (i.e. 32.4% and 36.3%, respectively), the lethality of attempts, as defined by a lower ratio of attempted to completed suicides, appears to be higher in individuals with bipolar II.

There might be an association between genetic markers and increased risk for suicidal behaviour among individuals with a bipolar disorder, including a 6.5-fold higher risk of suicide among first-degree relatives of individuals with bipolar II, as compared to first-degree relatives of individuals with bipolar I.

Functional Consequences

Many individuals with a bipolar disorder return to their euthymic baseline between mood episodes, and thereby return to a reasonable level of functioning. However, approximately 30% of individuals with bipolar I continue to show severe impairment in work functioning between mood episodes.

Recovery in functioning lags substantially behind recovery from symptoms, especially when it comes to occupational functioning. Consequently, individuals with bipolar I or bipolar II tend to have lower socioeconomic status despite equivalent levels of education, when compared with the general population.

On cognitive tests, individuals with bipolar I tend to perform more poorly than individuals from the general population. Such cognitive impairments might contribute to the vocational and interpersonal difficulties that tend to persist through the lifespan, even during the euthymic periods between mood episodes.

Both bipolar I and bipolar II are associated with reduced cognitive empathy, or an underdeveloped theory of mind, which is present even during euthymic periods between mood episodes, especially in relation to correctly identifying and reasoning about emotions. Colloquially, this might be described as a deficit in emotional intelligence.

Differential Diagnosis (Some Noteworthy Details)

When diagnosing a specific bipolar disorder, particular care must be taken to distinguish that disorder from:

major depressive disorder (MDD)

other bipolar disorders

schizophrenia spectrum and other related psychotic disorders

generalised anxiety disorder, panic disorder, post-traumatic stress disorder, or other anxiety disorders

substance use disorders

personality disorders

attention-deficit/hyperactivity disorder (ADHD)

disorders with prominent irritabilty

Rapid Cycling Bipolar I, Rapid Cycling Bipolar II

Both disorders may resemble cyclothymic disorder by virtue of the frequent marked shifts in mood. By definition in cyclothymic disorder the criteria for a major depressive, manic, or hypomanic episode has never been met, whereas the bipolar I and bipolar II specifier “with rapid cycling” requires that full mood episodes be present.

Anxiety-related Disorders

It is possible for a bipolar disorder to cooccur with an anxiety-related disorder, such that the anxiety-related disorder is either the primary disorder or merely a comorbid disorder. Nevertheless, in order to diagnose an individual with a bipolar-related disorder, anxiety-related disorders must be ruled out as the cause of a sufficient number of potentially bipolar-related symptoms. In particular, anxious rumination might be mistaken for the racing thoughts of a manic/hypomanic episode, and efforts to minimise anxious feelings (e.g. compulsions) might be mistaken as the impulsive behaviours of a manic/hypomanic episode.

In differentiating bipolar-related disorders from PTSD, it is helpful to note that the symptoms of a bipolar-related disorder tend to differ over time as a function of mood episodes, whereas the symptoms of PTSD do not tend to be episodic in this way. Additionally, the symptoms of PTSD tend to be caused or exacerbated by a limited number of specific triggers, which remain relatively constant over time, whereas bipolar-related symptoms do not tend to be linked to specific triggers in this way.

Substance/Medication-induced Symptoms

Substances and medications can induce bipolar-like symptoms (in particular, stimulants can acutely induce manic/hypomanic symptoms, and chronically induce major depressive symptoms). Accordingly…

Substance use disorders may manifest with substance/medication-induced manic symptoms, which have to be distinguished from symptoms of bipolar I. Response to mood stabilizers during substance/medication-induced mania may not necessarily be diagnostic for bipolar disorder. Moreover, there may be substantial overlap in substance use, since it is common for individuals with bipolar I to overuse substances during a manic/hypomanic episode. Ultimately, primary diagnosis of a bipolar disorder must be established based on symptoms that remain once the relevant substances are no longer being used.

Cyclothymic disorder must be distinguished from substance/medication-induced bipolar and related disorder and substance/medication-induced depressive disorder, based on the judgment that a substance/medication (especially a stimulant) is not etiologically related to the mood disturbance. The frequent mood swings in these latter disorders, which are suggestive of cyclothymic disorder, usually resolve following cessation of the substance/medication use.

Schizophrenia Spectrum and Other Related Psychotic Disorders

Bipolar I must be distinguished from psychotic disorders (e.g. schizoaffective disorder, schizophrenia, and delusional disorder), especially when it involves manic episodes that have psychotic features. Schizophrenia, schizoaffective disorder, and delusional disorder are all characterised by at least some periods of psychotic symptoms that occur in the absence of prominent mood symptoms. Other helpful considerations include the accompanying symptoms, previous course, and family history.

Personality disorders

Some presentations of personality disorders have substantial symptomatic overlap with bipolar disorders. This is especially true with borderline personality disorder (BPD), since mood lability and impulsivity are definitive symptoms of both BPD and bipolar disorders, and are commonly involved in presentations thereof. BPD is particularly difficult to distinguish from cyclothymic disorder, because the latter is characterised by mood symptoms that are less obviously episodic in nature, and can fluctuate in a seemingly reactive manner (thereby resembling BPD more closely).

It is possible for an individual to have a bipolar disorder as well as a comorbid personality disorder (indeed, the likelihood of having a personality disorder is higher than in the general population), and a dual diagnosis should be made if the full criteria are met for both conditions. However, a presentation of shared symptoms might be distinguished as an instance of a bipolar disorder rather than an instance of BPD on the following bases:

The symptoms are not always present, and clearly represent a distinct episode.

The onset of the symptoms represents a noticeable difference from baseline, in the manner required for the diagnosis of a bipolar disorder.

The symptoms of excessive mood do not appear to be elicited directly by the causes that are more standardly associated with BPD (e.g. relationship stress, anticipation of rejection or abandonment), or appear to be just as readily elicited by other circumstances.

Attention-deficit/Hyperactivity Disorder

ADHD is sometimes misdiagnosed as a bipolar disorder, especially in adolescents and children. Many of its possible symptoms overlap with symptoms of mania/hypomania, such as rapid speech, racing thoughts, distractibility, and a reduction in the felt need for sleep. The “double counting” of symptoms towards both ADHD and bipolar disorder can be avoided if the clinician clarifies whether the symptom(s) represents a distinct episode.

Disorders with Prominent Irritability

In individuals with severe irritability, particularly children and adolescents, care must be taken to diagnose with bipolar disorder only those who have had a clear episode of mania or hypomania—that is, a distinct time period, of the required duration, during which the irritability was clearly different from the individual’s baseline and was accompanied by the onset of manic/hypomanic symptoms. When a child’s irritability is persistent and particularly severe, the diagnosis of disruptive mood dysregulation disorder would be more appropriate. Indeed, when any child is being assessed for mania/hypomania, it is essential that the symptoms represent a clear change from the child’s typical behaviour.

Comorbidity

Bipolar I

Cooccurring mental disorders are exceedingly common, with the most frequent disorders being:

any anxiety disorder (e.g. panic disorder, social anxiety disorder, specific phobia), which occurs in approximately three-fourths of individuals with bipolar I

ADHD

any disruptive, impulse-control, or conduct disorder (e.g. intermittent explosive disorder, oppositional defiant disorder, or conduct disorder)

any substance use disorder (e.g. alcohol use disorder), occurring in over half of individuals with bipolar I

Adults with bipolar I also have high rates of serious and/or untreated cooccurring medical conditions. Metabolic syndrome and migraine are more common among individuals with bipolar I than in the general population.

As mentioned above, more than half of individuals who meet the criteria for bipolar I also have an alcohol use disorder, and those with both of these disorders are at a greater risk of suicide attempts.

Bipolar II

More often than not, bipolar II cooccurs with one or more other mental disorders, anxiety disorders being the most common.

Indeed, approximately 60% of individuals with bipolar II have three or more co-occurring mental disorders.

75% of bipolar II individuals have an anxiety disorder.

37% of bipolar II individuals have a substance use disorder.

Children and adolescents with bipolar II have a higher rate of cooccurring anxiety disorders compared to children and adolescents with bipolar I, and such an anxiety disorder most often predates the bipolar disorder.

In bipolar II individuals, anxiety and substance use disorders occur at a higher rate than in the general population.

Approximately 14% of bipolar II individuals have at least one lifetime eating disorder, with binge-eating disorder being more common than bulimia nervosa and anorexia nervosa.

Typically, these commonly cooccurring disorders do not seem to follow a course of illness that is truly independent from that of bipolar II, but instead seem to have strong associations with the excessive mood states of the bipolar disorder. For example, the symptoms of comorbid anxiety and eating disorders tend to be most strongly associated with depressive episodes, while substance use disorders are moderately associated with manic episodes.

Cyclothymic Disorder

Substance-related disorders and sleep disorders (i.e. difficulties in initiating and maintaining sleep) are often present in individuals with cyclothymic disorder.

Most children with cyclothymic disorder who are treated in outpatient psychiatric settings have comorbid mental conditions.

Moreover, compared to other pediatric patients who have mental disorders, such children are more likely to have comorbid ADHD.

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Major Depressive Disorder (per DSM-5)

In DSM-5 (2013; p. 160–8), the American Psychiatric Association defines major depressive disorder as follows. (Since I have covered states of major depression in an earlier post, the following definition will contain only a simplified characterisation of major depressive episodes.)

One has major depressive disorder (MDD) just in case:

one has had a major depressive episode (as defined here), a period of mood-related distress or impairment that lasts at least two weeks, and pervasively involves at least five symptoms that must include persisting negative mood or loss of interest or pleasure (or both), together with some combination of appetite disturbance, sleep disturbance, psychomotor disturbance, fatigue, negative self-appraisal, cognitive-executive disturbance, and suicidal ideation.

This episode is not better explained by a schizophrenia-related or psychotic disorder.

One has never had a manic or hypomanic episode.

Diagnostic Features

For individuals with MDD, insomnia or fatigue are often the presenting complaints; with such presentations, failing to probe for accompanying depressive symptoms will result in underdiagnosis. Fatigue and sleep disturbance are also present in a high proportion of MDD cases. Psychomotor disturbances are much less common, but they are indicative of greater overall severity, as is the presence of delusional or near-delusional guilt.

Major depressive episodes must be accompanied by clinically significant distress or impairment in social, occupational, or other important areas of functioning. For some individuals (with milder depressive episodes), functioning may appear to be normal, but nevertheless requires disproportionate or markedly increased effort.

Per the persisting negative mood symptom, the mood in a major depressive episode is often described by the person as depressed, sad, hopeless, discouraged, or “down in the dumps”. Sadness may be denied at first, but subsequently elicited by interview (e.g. by pointing out that the individual looks as if he or she is about to cry) or inferred from facial expression and demeanour.

Moreover, in some anhedonic individuals who complain of feeling apathetic or having no feelings, and in some individuals who mainly present with anxiety, the presence of a negative mood also may be inferred from facial expression and demeanour.

Some individuals emphasise somatic complaints (e.g. bodily aches and pains) rather than reporting feelings of sadness (clinicians should determine whether the distress from such complaints is associated with specific depressive symptoms).

Many individuals with MDD report or exhibit increased irritability (e.g. persistent anger, a tendency to respond to events with angry outbursts or blaming others, or an exaggerated sense of frustration over minor matters). In depressed children and adolescents, an irritable or cranky mood may develop instead of a noticeably sad or dejected mood. Such a presentation of MDD should be differentiated from merely having a pattern of irritability in response to frustration.

Loss of interest or pleasure is nearly always present in a major depressive episode, at least to some degree. Individuals may report feeling less interested in hobbies, “not caring anymore,” or not feeling any enjoyment in activities that were previously considered pleasurable. Family members often notice social withdrawal or neglect of pleasurable avocations (e.g. a formerly avid golfer no longer plays, a child who used to enjoy soccer finds excuses not to practise). In some individuals, there is a significant reduction from previous levels of sexual interest or desire.

Appetite disturbance may consist in either a reduction or an increase. Some depressed individuals report that they have to force themselves to eat. Others may eat more and may crave specific foods (e.g. sweets or other carbohydrates). When appetite changes are severe (in either direction), there may be a significant loss or gain in weight—or, in children, a failure to make expected weight gains may be noted.

Sleep disturbance may take the form of either difficulty sleeping (insomnia) or sleeping excessively (hypersomnia). When insomnia is present, it typically takes the form of so-called middle insomnia (i.e. waking up during the night and then having difficulty returning to sleep) or terminal insomnia (i.e. waking too early and being unable to return to sleep). Although these forms of insomnia are most common, initial insomnia (i.e. difficulty falling asleep) may also occur. Individuals who present with hypersomnia may experience prolonged sleep episodes at night or increased daytime sleep. Sometimes, disturbed sleep is the reason that the individual seeks treatment.

Psychomotor disturbance potentially includes psychomotor agitation (e.g. the inability to sit still, pacing, hand-wringing; or pulling or rubbing of the skin, clothing, or other objects) or psychomotor retardation (e.g. slowed speech, thinking, and body movements; increased pauses before answering; speech that is decreased in volume, inflection, amount, or variety of content, or muteness). The psychomotor agitation or retardation must be severe enough to be observable by others and not represent merely subjective feelings of restlessness or sluggishness.

Fatigue, decreased energy, and tiredness are also common. A person may report sustained fatigue without any physical exertion. Even the smallest tasks may seem to require substantial effort. The efficiency with which tasks are accomplished may be reduced. For example, an individual may complain that washing and dressing in the morning are exhausting and take twice as long as usual.

Excessive negative self-appraisal tends to be involved in major depression. The sense of worthlessness or guilt associated with a major depressive episode may include unrealistic negative evaluations of one’s worth, or guilty preoccupations or ruminations over relatively minor past failings. Such individuals often misinterpret neutral or trivial day-to-day events as evidence of personal defects, and have an exaggerated sense of responsibility for untoward events.

In major depression, the felt sense of worthlessness or guilt may be of delusional proportions (e.g. an individual who is convinced that he or she is personally responsible for world poverty). Indeed, among major depressive episodes that have psychotic features, such delusions related to negative self-appraisal are the most common psychotic feature. For obvious reasons, such delusions are considered to be mood-congruent in the course of a major depressive episode, as opposed to mood-incongruent. (Interestingly, grandiose delusions are probably the most common psychotic feature of manic episodes, which suggests that self-appraisal delusions are the most common psychotic feature of disturbed moods in general, tending to be negative in the depressive case and positive in the manic case.)

Blaming oneself for being sick, and blaming one’s self for failing to meet occupational or interpersonal responsibilities due to illness (in this case, major depression), are both very common; unless such instances of self-blame reach the level of delusion, they are not considered to be sufficient for the negative self-appraisal symptom.

Many individuals report cognitive-executive disturbance, in the form of an impaired ability to think, concentrate, or make even minor decisions. Individuals with this symptom also may appear easily distracted, or complain of memory difficulties. Individuals engaged in cognitively demanding pursuits are often unable to function in those pursuits. In children, a precipitous drop in grades may reflect a depressive impairment of concentration. In elderly individuals, memory difficulties may be the chief complaint, and may be mistaken for early signs of a dementia (i.e. “pseudodementia”). In such cases, when the major depressive episode is successfully treated, the memory problems often fully abate. However, in some individuals, particularly elderly persons, a major depressive episode may sometimes be the initial presentation of an irreversible dementia.

Suicidal ideation, thoughts of death, and suicide attempts are common features of major depression. They range from passively wishing not to awaken in the morning, or believing that others would be better off if one were dead, to transient but recurrent thoughts of committing suicide, to having a specific suicide plan. More severely suicidal individuals may have already put their affairs in order (e.g. updated wills, settled debts), acquired needed materials (e.g. a rope or a gun), and chosen a location and time to commit suicide.

Common depressive motivations for suicide include a desire to give up in the face of perceived insurmountable obstacles (felt hopelessness), an intense wish to end what is perceived as an unending and excruciatingly painful emotional state (persistent and intense negative feelings, emotional pain), an inability to foresee any enjoyment in life (anhedonia), or the wish to not be a burden to others (negative self-appraisal). Reducing such motivations in the individual, by improving the associated patterns of thinking, seems to be a more meaningful preventative measure against suicide risk than impeding that individual’s plans for suicide.

The evaluation of the symptoms of a major depressive episode is especially difficult when they occur in an individual who also has a general medical condition (e.g. cancer, stroke, myocardial infarction, diabetes, pregnancy). For one thing, some of the criterial signs and symptoms of a major depressive episode are identical to those of general medical conditions (e.g. weight loss with untreated diabetes; fatigue with cancer; hypersomnia early in pregnancy; insomnia later in pregnancy or the postpartum). Such symptoms do count towards a major depressive diagnosis, but not when they are clearly and fully attributable to a general medical condition. In cases involving a general medical condition, particular care should be taken to assess the presence of guilt or felt worthlessness, impaired concentration or indecision, suicidal thoughts, or non-vegetative symptoms of dysphoria or anhedonia. Such symptoms are particularly central to major depression (redefinitions of major depression that include only these symptoms appear to identify nearly the same individuals as do the full criteria).

Associated Features

MDD is associated with high mortality, much of which is accounted for by suicide; however, suicide is not the only associated cause. For example, depressed individuals admitted to nursing homes have a markedly increased likelihood of death in the first year.

Depressed individuals frequently present with tearfulness, irritability, brooding, obsessive rumination, anxiety, phobias, excessive worry over physical health, and complaints of broadly somatic pain (e.g. headache, joint, abdominal, or other pains). In depressed children, separation anxiety may be more likely to occur.

Although an extensive literature exists describing neuroanatomical, neuroendocrinological, and neurophysiological correlates of MDD, no laboratory test has yielded results of sufficient sensitivity and specificity to be used as a diagnostic tool for MDD.

Until recently, hypothalamic-pituitary-adrenal (HPA) axis hyperactivity had been the most extensively investigated abnormality associated with major depressive episodes. HPA hyperactivity does appear to be associated specifically with melancholic features, psychotic features, and an increased risk for eventual suicide.

Neuro-molecular studies have implicated certain peripheral factors, including genetic variants in factors that regulate neuronal generation (i.e. neurotrophic factors) and cytokines that promote neurological inflammation. Additionally, functional magnetic resonance imaging has provided evidence for functional abnormalities in specific neural systems that support emotion processing, reward seeking, and emotion regulation.

Prevalence

Twelve-month overall prevalence of MDD in the United States is approximately 7%.

There are marked differences by age group, such that the prevalence in 18- to 29-year-old individuals is threefold higher than the prevalence in individuals age 60 years or older.

From early adolescence onwards, females have a 1.5- to 3-fold higher rate of MDD than males.

Development and Course

The first major depressive episode (marking the onset of MDD) may occur at any age, but the likelihood of onset increases markedly at and after puberty. In the United States, incidence appears to peak in the 20s; however, first onsets in late life are not uncommon.

The course of MDD is quite variable; some individuals rarely if ever experience remission (a period of 2 or more months without depressive symptoms, or with only one or two symptoms of mild degree), while others experience many years with few or no symptoms between discrete episodes.

Clinically, it is important to distinguish individuals who present for treatment during an exacerbation of a chronic depressive illness from those whose symptoms have developed only recently. Chronicity and pervasiveness of depressive symptoms substantially increase the likelihood of having underlying personality, anxiety, and substance use disorders, and decrease the likelihood that depressive symptoms will be fully resolved by and after treatment. It is therefore useful to ask individuals presenting with depressive symptoms to identify the last period of at least 2 months during which they were entirely free of depressive symptoms.

For four in five individuals with MDD, recovery begins within 1 year of onset; for two of those four individuals, recovery begins within 3 months of onset.

Recency of onset is a strong determinant of the likelihood of near-term recovery, and many individuals who have been depressed only for several months can be expected to recover spontaneously. Other than the duration of the current depressive episode, features associated with lower recovery rates include psychotic features, prominent anxiety, personality disorders, and symptom severity.

While longer periods of depressive symptoms decrease the likelihood of recovery, longer periods of remission also decrease the likelihood of a major depressive episode. The risk of recurrence becomes progessively lower over time as the duration of remission increases.

The risk of recurrence is higher in individuals whose preceding episode was severe, younger individuals, and individuals who have already experienced multiple episodes.

Failure to fully return to euthymic baseline after a major depressive episode—i.e. the persistence of even mild depressive symptoms during remission—is a powerful predictor of recurrence.

Many bipolar illnesses begin with one or more depressive episodes, and a substantial proportion of individuals who initially appear to have MDD will prove, in time, to instead have a bipolar disorder. This is more likely in individuals with onset of the illness in adolescence, those whose depression involves psychotic features, and those with a family history of bipolar illness. Depressive episodes with mixed features (i.e. episodes accompanied by some features of mania/hypomania) also increase the risk of having a future manic or hypomanic episode (and a corresponding bipolar diagnosis).

MDD, particularly if it involves depression with psychotic features, may transition into schizophrenia. Such a change in diagnostic symptoms is much more frequent than the reverse (i.e. it is more frequent that initially meeting the criteria for schizophrenia, then continuing to have major depressive episodes but never again having symptoms that would meet the full criteria for schizophrenia).

Despite consistent differences between genders in the prevalence rates for depressive disorders (with higher prevalence for females), there appear to be no clear differences by gender in MDD’s phenomenology, course, or treatment response.

Similarly, there are no clear effects of current age on the course or treatment response of MDD. Some symptom differences exist, though, such that hypersomnia and hyperphagia (over-eating) are more likely in younger individuals, and melancholic symptoms, particularly psychomotor retardation, are more common in older individuals. The likelihood of suicide attempts lessens in middle and late life, although the risk of completed suicide does not.

Cases of MDD that have earlier ages of onset are more likely to be familial, and more likely to involve personality disturbances.

The course of MDD does not generally change with aging. Mean times to recovery appear to be stable over long periods, and the likelihood of being in a major depressive episode does not generally increase or decrease with time.

Risk and Prognostic Factors

Temperamental

Higher trait neuroticism (negative affectivity) is a well-established risk factor for the onset of MDD, and high levels appear to render individuals more likely to develop depressive episodes in response to stressful life events.

Environmental

Adverse childhood experiences, particularly when there are multiple experiences of diverse types, constitute a set of potent risk factors for MDD.

Stressful life events are well recognised as precipitants of major depressive episodes, but the presence or absence of adverse life events near the onset of episodes does not appear to provide a useful guide to prognosis or treatment selection.

Genetic and physiological

First-degree family members of individuals with MDD have a risk for MDD that is two- to four-fold higher than that of the general population. The risk to family members appears to be higher for individuals that have early-onset and recurrent forms of MDD.

The heritability of MDD is approximately 40%, and the heritability of the personality trait neuroticism accounts for a substantial portion of this genetic liability.

Course modifiers

Essentially, all major non-mood disorders increase the risk of an individual developing symptoms of major depression.

Major depressive episodes that develop against the background of another disorder often follow a more refractory course. Substance use, anxiety, and borderline personality disorders are among the most common of these comorbid disorders, and the detection of such disorders may be obscured or delayed by presenting depressive symptoms. Nevertheless, in such cases, sustained clinical improvement in the depressive symptoms may depend on the appropriate treatment of the underlying mental illnesses.

Chronic or disabling medical conditions also increase risks for major depressive episodes. Such prevalent illnesses as diabetes, morbid obesity, and cardiovascular disease are often complicated by depressive episodes, and such episodes are more likely to become chronic than are depressive episodes in medically healthy individuals.

Culture-Related Diagnostic Issues

Surveys of MDD across diverse cultures have shown seven-fold differences in prevalence, but much more consistency in the female-to-male ratio, mean ages at onset, and the degree to which the presence of the disorder raises the likelihood of comorbid substance abuse.

While these findings suggest substantial cultural differences in the expression of MDD, they do not permit simple linkages between particular cultures and the likelihood of specific symptoms. Instead, clinicians should be aware that in most countries the majority of cases of depression go unrecognised in primary care settings, and that in many cultures somatic symptoms are much more likely to constitute the presenting complaint.

Among the possible symptoms of major depression, insomnia and loss of energy are the most uniformly reported across cultures.

Gender-Related Diagnostic Issues

The most reproducible finding in the epidemiology of MDD has been a higher prevalence in females. Despite this, there are no clear differences between genders in overall symptoms, course, treatment response, or functional consequences.

In women with depressive disorders, as compared to men with depressive disorders, the risk for suicide attempts is higher while the risk for suicide completion is lower. But these gendered disparities in suicide risk are actually independent of major depression. In fact, while depressive disorders generally increase the risks of suicide attempt and completion (for both genders), they decrease the gendered disparity in these risks. In other words, although women are more likely to attempt suicide and men are more likely to complete suicide among individuals that have depressive disorders, this difference between the genders is ever larger in the general population.

Suicide Risk

The possibility of suicidal behavior exists at all times during major depressive episodes. The most consistently described risk factor is a past history of suicide attempts or threats, but it should be remembered that most completed suicides are not preceded by unsuccessful attempts.

Overall, features associated with an increased risk for completed suicide are:

previous suicide attempts or threats

being male

being single or living alone

having prominent feelings of hopelessness.

The risk of future suicide attempts is markedly increased when there is comorbid borderline personality disorder.

Functional Consequences of MDD

Many of the functional consequences of MDD derive from the individual symptoms. Impairment can be very mild, such that many of those who interact with the affected individual are unaware of the depressive symptoms. Impairment may, however, range to complete incapacity—such that the depressed individual is unable to attend to basic self-care needs, or is mute or catatonic. Among individuals seen in general medical settings, those with MDD have more pain and physical illness, and greater decreases in physical, social, and role functioning.

Differential Diagnosis

Irritable manic episodes, mixed mood episodes

Major depressive episodes with prominent irritable mood may be difficult to distinguish from manic episodes with irritable mood, or from mixed depressive/manic episodes. This distinction requires a careful clinical evaluation of the presence of manic symptoms.

Substance/medication-induced depressive or bipolar disorder

These disorders are distinguished from MDD by the fact that their mood disturbances are directly related etiologically to a substance (e.g. a drug of abuse, a medication, or a toxin) For example, depressed mood that occurs only in the context of withdrawal from cocaine would be diagnosed as cocaine-induced depressive disorder rather than MDD.

Attention-deficit/hyperactivity disorder (ADHD)

There is some overlap in symptoms between MDD and ADHD. In particular, distractibility and low frustration tolerance are common in both ADHD and major depressive episodes. Nevertheless, if an individual meets the criteria for both MDD and ADHD, then both disorders should be diagnosed.

Relatedly, when children with ADHD present with mood disturbances characterised by irritability (rather than by sadness or loss of interest/pleasure), care must be taken not to diagnose MDD solely on the basis of such disturbances (the excessive irritability in such children may be best explained in terms of ADHD alone, in the absence of MDD).

Adjustment disorder with depressed mood

When major depressive symptoms occur in response to a psychosocial stressor, MDD is distinguished from adjustment disorder with depressed mood by the fact that in the latter disorder, full criteria for a major depressive episode are not met.

Normal Sadness

Finally, it should be noted that periods of sadness are inherent aspects of the human experience. Such periods should not be diagnosed as major depressive episodes unless criteria are met for sufficient severity (i.e. the period of sadness pervasively includes five out of the nine possible symptoms of major depression), sufficient duration (i.e. the symptoms are present most of the day, nearly every day, for at least 2 weeks), and clinically significant distress or impairment. A diagnosis of other specified depressive disorder may be appropriate for presentations of major depressive symptoms that cause clinically significant impairment but do not meet criteria for sufficient severity and duration.

Comorbidity

Other disorders with which MDD frequently co-occurs are substance-related disorders, panic disorder, obsessive-compulsive disorder, anorexia nervosa, bulimia nervosa, and borderline personality disorder.

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