PSYCHIATRY III suicide attempt or a specific plan for committing

MOOD DISORDERS suicide.

By: Jocelyn Nieva Yatco-Bautista, M.D.  Always ask if meron nang specific plan
B) The symptoms do not meet the criteria for a mixed
The difference between mood and affect episode.
 Mood – pervasive and sustained emotion experienced C) The symptoms cause clinically significant distress or
by the individual; subjectively experienced by the impairment in social, occupational, or other important
individual areas of functioning.
 Affect – observed expression of emotions D) The symptoms are not due to the direct physiological
effects of a substance (eg. a drug of abuse, a medication) or
a general medical condition (eg. hypothyroidism).
Mood Disorders E) The symptoms are not better accounted for by
A. Depression bereavement, like after the loss of a loved one, the
 Major Depressive Disorder symptoms persist for longer than 2 months or are
 Dysthmic Disorder characterized by marked functional impairment, morbid
B. Bipolar Disorders preoccupation with worthlessness, suicidal ideation,
 Manic Disorder psychotic symptoms, or psychomotor retardation.
 Mixed Episode  so bereavement is normal only up to 2 months
 Hypomanic Episode
MAJOR DEPRESSIVE DISORDER (MDD)
 Cyclothymic Episode
 Rapid Cycling Epidemiology .
Incidence and Prevalence
PART 1 – DEPRESSION  Common psychiatric disorder
 Lifetime prevalence
Sample case 1 o 10-25% for women
A 48-year-old woman presents with a 2-month history of o 5-12% for men
sadness, initial and terminal insomnia, lethargy, inability to work or
concentrate, and a lack of interest in her activities. The symptoms SEX
began. She was brought in by her husband when she bagan talking  twofold greater prevalence in women than in men
about suicide.  reasons:
 A case of depression  hormonal differences
 effects of childbirth
DEPRESSION  differing psychosocial stressors
 Characterized by lifelong vulnerability to episodes of  behavioral models of learned helplessness
disease, involving depressed mood or loss of interest
and pleasure in activities AGE
 Characterized by depressive symptomatology  mean age of onset is 40 years
 A feeling of sadness  50% of all patients having an onset between the ages of
20 and 50
Depression becomes a disorder when it satisfies the criteria:  can also begin in childhood or old age
DSM-IV-TR Diagnostic Criteria for Major Depressive Episode  increasing among people less than 20 years (increased
use of alcohol and drugs of abuse)
A) Five or more of the following symptoms have been MARITAL STATUS
present during the same 2-week period and represent a  occurs most often in persons without close interpersonal
change from previous functioning: at least one of the relationships, sa mga “singles for life”
symptoms is either (1) depressed mood or (2) loss of  those who are divorced or separated
interest or pleasure.
[ note: do not include symptoms that are clearly due to a general
medical condition, or mood-incongruent delusions or SOCIOECONOMIC AND CULTURAL FACTORS
hallucinations.]  no correlation has been found between socioeconomic
i) depressed mood most of the day, nearly every day, as status and MDD
indicated by either subjective report (eg. feels sad or  more common in rural than in urban areas
empty) or observation made by others (eg. appears  no difference among races
tearful, or sasabihin ng parents, doktora palagi po yan
nagkukulong sa kwarto) Ten Primary Risk Factors for Depression
 note: in children and adolescents, can be irritable mood (Depression Guideline Panel)
ii) markedly diminished interest or pleasure in all, or 1) history of prior episodes of depression
almost all, activities most of the day, nearly everyday 2) family history of depressive disorder, esp. in first-degree
(as indicated by either subjective account or observation
made by others)
relatives
 genetics is a very strong factor
iii) significant weight loss when not dieting or weight gain
3) history of suicide attempts
(eg. change of more than 5% of body weight in a month), or
4) female gender
decrease or increase in appetite nearly every day.
 note: in children, consider failure to make expected weight
5) age of onset before age 40
gains 6) postpartum period
iv) Insomnia or hypersomnia nearly everyday 7) comorbid medical illness
 Usually insomnia 8) absence of social support
v) Psychomotor agitation or retardation nearly everyday 9) negative, stressful life events
(observable by others, not merely subjective feelings of 10) active alcohol or substance abuse
restlessness or being slowed down)
vi) Fatigue or loss of energy nearly every day Etiology .
vii) Feelings of worthlessness or excessive or 1. biological factors
inappropriate guilt (which may be delusional) nearly 2. genetic factors
every day (not merely self-reproach or guilt about being 3. psychosocial factors
sick)
 Feeling nila wala na silang tamang ginawa, at wala silang
saysay
 BIOLOGICAL FACTORS
viii) Diminished ability to think or concentrate, or  Biogenic Amines
indecisiveness nearly every day (either by subjective  Mood disorders are associated with heterogenous
account or as observed by others) dysregulation of the biogenic amines
 Bumababa ang grades sa school  NE and serotonin – 2 neurotransmitters most
ix) Recurrent thoughts of death (not just fear of dying), implicated in the pathophysiology of mood disorders
recurrent suicidal ideation without a specific plan, or a  Serotonin: neurotransmitter most commonly
associated with depression
 pinakaimportante sa depression ay serotonin, sa
mood disorders – norepinephrine and serotonin
 Depletion of serotonin may precipitate depression
 Patients with suicidal impulses have low CSF
concentrations of serotonin metabolites and low
concentrations of serotonin metabolites and low
concentrations of serotonin uptake sites on platelets
 Dopamine – dopamine activity may be reduced in
depression
 Theories on why dopamine affects mood:
1. mesolimbic dopamine pathway may be
dysfunctional
2. dopamine D1 receptor may be hypoactive
 Other Neurochemical Factors
1. amino acid neurotransmitters
(GABA)
2. neuroactive peptides (vasopressin
and endogenous opiates)
 Neuroendocrine Regulation
 Adrenal axis – hypersecretion of cortisol
 Thyroid axis – thyroid disorders are often found in
about 5-10% of persons with depression
 Growth Hormone – depressed patients have a
blunted sleep-induced stimulation of growth
hormone release
 Decreased nocturnal secretion of melatonin
 Decreased prolactin release
 Decreased basal levels of FSH and LH
 Decreased testosterone levels in men
 Sleep Abnormalities
 Circadian rhythms
 Neuroimmune regulation
 Brain imaging
 Kindling – electrophysiological process in which
repeated subthreshold stimulation of a neuron
eventually generates an action potential (of an area
of the brain result in seizure)
 anticonvulsants (carbamazepine and valproic acid)
were found to work on mood disorders especially on
bipolar disorders, so naisip nila that kindling might
have something to do with mood disorders, since
nagwork ang anticonvulsants
 Neuroanatomical Considerations
 Pathology of the limbic system, basal ganglia, and
hypothalamus
 Limbic system may play a major role in the production
of emotions
 Alteration in sleep, appetite, sexual behavior and
biological changes → dysfunction of the
hypothalamus
 Stooped posture, motor slowness, and minor
cognitive impairment → dysfunction of the basal
ganglia
 GENETIC FACTORS
 Family studies
o First degree relatives of MDD probands are 2 to 3
times more likely to have MDD
 Adoption Studies
o Two of three adoption studies have found a strong
genetic component for the inheritance of MDD
o Biological children of affected parents remain at
increased risk of a mood disorder, even if they are
reared in nonaffected adoptive families
 Twin Studies
 Linkage Studies
 PSYCHOSOCIAL FACTORS
 Life events and environmental stressors
o The life event most often associated with
development of depression is losing a parent before
age 11
o The environmental stressor most often associated
with the onset of an episode of depression is the loss
of a spouse
o Unemployment
 Personality factors – no single predisposing personality
factor
 Psychodynamic/Psychosocial factors
o Freud and Abraham – most classical
o disturbances in the infant-mother relationship
during the oral phase predispose to subsequent
vulnerability to depression
o depression can be linked to real or imagined object
loss
maybe the mother is always out, an overseas
worker maybe
o introjection of the departed objects is a defense
mechanism invoked to deal with the distress
connected with the object’s loss
yung characteristic ng isang tao, kinukuha niya –
that’s introjection. kung absentee mother, yung
characteristics ng mother ang kinukuha niya
o because the lost object is regarded with a mixture
of love and hate, feelings of anger are directed
inward at the self
sinasaktan niya ang sarili niya, kaya merong
suicide, bigla nalang tatalon
o Klein – expression of aggression toward loved ones
o Arieti – depressed people have lived their lives for
someone else (dominant other) rather than for
themselves; depression sets in when patients realize
that the person or ideal for whom they have been
living is never going to respond in a manner that will
meet their expectations
the dominant individual may be an individual, an
ideal, a principle, or an institution; for example
yung tao for 20 years nagttrabaho na sa UST, and
inexpect niya na after 20 years iapagtatayo siya
ng statwa, but no, na-forced retirement pa, ayun
nadepress tuloy.
o Kohut – developing self has specific needs that must
be met by parents to give the child a positive sense of
self-esteem and self-cohesion; when others do not
meet these needs, there is a massive loss of self-
esteem that presents as depression
o Bowlby – damaged early attachments and traumatic
separation in childhood predispose to depression;
adult losses are said to revive the traumatic childhood
loss and precipitate adult depressive episodes
so laging may loss, usually sa depression, may loss of an object
 OTHER FORMULATIONS OF DEPRESSION
Cognitive Theory
 Depression results from specific cognitive distortions
present in persons prone to depression
 Beck’s cognitive triad of depression:
1. view about the self – a negative self-precept
2. about the environment – a tendency to experience
the world as hostile and demanding
3. about the future – the expectation of suffering and
failure
Learned Helplessness Models and Hopelessness Theory
 Regard stressful events as permanent rather as
temporary, and affecting most of one’s life rather than
a specific aspect of one’s life
Clinical Features .
 Depressed mood
 Loss of interest or pleasure
 Feel blue, hopeless, in the dumps, or worthless
 About 2/3 of all depressed patients contemplate suicide;
10-15% commit suicide
 Reduced energy, difficulty finishing tasks, impaired at
school and work, less motivation to undertake new
projects (97%)
 Trouble sleeping, early morning awakening and multiple
awakenings at night (80%)
 Decreased appetite and weight loss
 Anxiety is a common symptom (90%)
 Sexual problems
 Cognitive symptoms, inability to concentrate and
impairments in thinking
Treatment .
Hospitalization - Indications
o Need for diagnostic procedures
o Risk of suicide or homicide
o Patient’s grossly reduced ability to get food and
shelter
o Rapidly progressing symptoms
o Rupture of a patient’s usual support systems
 this morning for breakfast”. The patient described the pace of his
Psychosocial Therapy
thoughts as racy. He was unable to explain how he got into the fight
 Cognitive therapy other than to say that the other person was jelous of the patient’s
 Interpersonal therapy obvious sexual ability, the patient having declared that he had slept
 Behavior therapy with at least a hundred women.
 Psychoanalytically oriented therapy He hadn’t slept in three days. “I don’t need it” he says. The
patient’s speech was full of amusing jokes and plays on words.
 Family therapy
 a case of bipolar disorder
Pharmacotherapy
 Tricyclics – imipramine (Tophranyl), clomipramine, BIPOLAR DISORDER
trimipramine  patients will present with mania, with or without
 Selective Serotonin Reuptake Inhibitors (SSRIs): depression
fluoxetine (Prozac), sertraline, paroxetine (Paxyl),  if a patient presents with mania without depression, that
escitalopram, fluvoxamine will still constitute a bipolar disorder
 Serotonin Norepinephrine Reuptake Inhibitors (SNRIs):  if you see “bipolar” – that means Bipolar I disorder
venlafaxine (efexor), duloxetine (simbalta)  requirement for diagnosis –> manic episode – aka
 Alpha-2-Adrenergic Antagonist: mirtazapine unipolar mania, pure mania, or euphoric mania
 usually, give only one anti-depressant drug, or sometimes if hindi
makatulog ang pasyente, also give a benzodiazepine like Epidemiology_
clonazepam  age of onset for Bipolar I disorder is earlier than that of
Electroconvulsive Therapy (ECT) - Indications MDD. it can start as early as in childhood – 5-6 years old,
o Unresponsive to pharmacotherapy and as late as during the 50’s. It peaks at around the 30’s
o Cannot tolerate pharmacotherapy  Bipolar disorders like MDD are also more common in
o Clinical situation is so severe that the rapid divorced patients
improvement seen with ECT is needed  Bipolar I disorder is more common in the upper
socioeconomic groups, whereas for MDD, there is no
DYSTHMIC DISORDER correlation
 It is also more common in persons who did not graduate
 Chronic disorder from college
 Patients complain that they have always been depressed  Genetics
 Core concept refers to a subaffective or subclinical  First degree relatives are 8-18 times more likely to
depressive disorder with: have it than those who are not related
o Low-grade chronicity for at least 2 years  50% of all Bipolar I patients have at least 1 parent
o Insidious onset, with origin often in childhood or with mood disorder, often MDD
adolescence  If 1 parent has Bipolar I disorder there is a 25%
o Persistent or intermittent course chance that the child will have it
Clinical Features .  If both parents have Bipolar I disorder, there is a 50-
75% chance that the child will have a mood disorder
 Feelings of inadequacy, guilt, irritability and anger
 Psychodynamic factors
 Withdrawal from society
 most theories of mania view manic episodes as a
 Loss of interest
defense against underlying depression
 Inactivity and lack of productivity  Abraham – manic episodes may reflect an inability
Epidemiology . to tolerate a developmental trajedy such as the loss
o Lifetime prevalence of a parent
 4.1% for women  Lewin –
 2.2% fro men  Klein – it is also a defensive reaction to depression
o in adults, more common in women using manic defenses such as omnipotence in which
the person develops delusions of grandiosity
Etiology . – more or less the same as MDD  para hindi malaman ng mga tao na depressed siya,
palalabasin niya na napakagaling niya, napakasikat
 BIOLOGICAL FACTORS niya, napakadami niyang alam
 Sleep studies
 Neuroendocrine studies Clinical Features_
 PSYCHOSOCIAL FACTORS  elevated, expansive mood is the hallmark of a patient with
 Psychodynamic theories – results from personality bipolar disorder
and ego dev’t and culminates in difficulty adapting to  elevated mood is euphoric and often infectious
adolescence and young adulthood  mood may be irritable, especially if the don’t get what they
 Cognitive theory – a disparity between actual and want
fantasized situation leads to diminished self-esteem  often drink alcohol excessively
and a sense of helplessness  excessive use of the telephone
Treatment .  pathological gambling
 Combination of pharmacotherapy and either cognitive or  uses jewelry and clothing of bright colors in unusual or
behavior therapy may be the most effective treatment outlandish combination
 inattention to small details
 act impulsively – tendency to buy things
 preoccupied by religious, political, financial, or sexual
ideas
Mental Status exam
 General
 excited, talkative
 sometimes amusing
 hyperactive
 Mood, affect, feelings
 euphoric
 irritable
PART 2 – BIPOLAR DISORDERS
 low frustration tolerance
 emotionally labile
Sample case 2
A 40 year old man was taken to the ER after becoming
 speech
involved in fist fight at a bar. He was speaking rapidly, jumping from  cannot be interrupted
one thought to another in response to simple specific questions like  if disturbed, becomes louder, more rapid, more
“when did you come to new york:?” – “I came to new york, the big difficult to interpret
apple, it’s rotten to the core, no matter how you slice it, I sliced a bread
  filled with jokes, rhymes, plays on words, and iv. flight of ideas or subjective experience that thoughts
irrelevancies are racing
 flight of ideas, word salads, neologisms, associations v. distractability (attention too easily drawn to unimportant
become loosened or irrelevant external stimuli)
 by the way when you say flight of ideas, the ideas are vi. increase in goal-directed activity (either socially, at
still somehow connected/related unlike in psychotic work or school, or sexually) or psychomotor gitation
disorders like schizophrenia (looseness of vii. excessive involvement in pleasurable activities that
association) where the ideas are not related anymore have a high potential for painful consequences (eg.
 Perceprtual disturbances engaging in unrestrained buying sprees, sexual
 delusions in 75% indiscretions, or foolish business investments)
 great wealth, extraordinary abilities or power C. The symptoms do not meet the criteria for a mixed
 Thought episode.
 themes of self-confidence and self-aggrandizement D. The mood disturbance is sufficiently severe to cause
 easily distracted marked impairment in occupational functioning or in usual
 accelerated flow of ideas social activities or relationships with others, or to
 impulse control is very poor to the point that they are necessitate hospitalization to prevent harm to self or
assaultive and threatening others, or there are psychotic features.
 judgement and insight are impaired, they often break the E. The symptoms are not due to the direct physiological
law effects of a substance (eg. a drug of abuse, a medication) or
 they have poor insight a general medical condition (eg. hyperthyroidism).
 Maniclike episodes that are clearly caused by somatic
Course_ antidepressant tretment (medication, electroconvulsive
therapy, light therapy) should not count toward a
 Bipolar I disorder often starts with depression diagnosis of bipolar I disorder.
 10-20% experience only a manic episode
 90% of those who had a single manic episode are likely to HYPOMANIA – BIPOLAR II (plus depression)
have another manic episode
 5-15% are rapid cyclers DSM-IV-TR Diagnostic Criteria for Hypomanic Episode

A. A distinct period of abnormally and persistently elevated,

Prognosis_ expansive, or irritable mood, lasting throughout at least 4
 Bipolar disorder I has a poorer prognosis than MDD days, that is clearly different from the ususal
 factors that contribute to a poor prognosis nondepressed mood.
 male B. During the period of mood disturbance, three or more of
 depressive features the following symptoms have persisted (four of the mood
 psychotic features is only irritable) and have been present to a significant
 alcohol dependence degree:
 premorbid poor occupational status i. inflated self-esteem or grandiosity
 Characteristics that lean towards a good prognosis  feeling niya bidang bida siya, walang magaling kundi
 short duration of manic episode sarili niya. siya lang ang tama – over confident
 advanced age of onset ii. decreased need for sleep (eg. feels rested after only 3
hours of sleep)
 few suicidal thoughts
 few coexisting problems iii. more talkative than usual or pressure to keep talking
iv. flight of ideas or subjective experience that thoughts
are racing
Treatment_
v. distractability (attention too easily drawn to unimportant
 usually require hospitalization or irrelevant external stimuli)
 Psychosocial therapy vi. increase in goal-directed activity (either socially, at
 Pharmacotherapy work or school, or sexually) or psychomotor gitation
 Mood stabilizers = anti-manic medications vii. excessive involvement in pleasurable activities that
 Lithium (Kilonium?) – standard treatment for have a high potential for painful consequences (eg.
 has an effect on the kidney - nephrotoxic, so make engaging in unrestrained buying sprees, sexual
sure to test the patient’s kidney function before indiscretions, or foolish business investments)
administration; request for BUN or Crea C. The episode is associated with an unequivocal change in
 also, monitor the blood level functioning that is characteristic of the person when not
 blood level of 0.8 – 1.2 mEq/L is the effective symptomatic.
range D. The disturbance in mood and the change in functioning
 Anticonvulsants are observable by others.
 Valproate E. The episode is not severe enough to cause marked
 Carbamazepine impairment in occupational functioning or in usual social
 Lamotrigine activities or relationships with others, or to necessitate
 Gabapentin hospitalization to prevent harm to self or others, and there
 Topiramate are no psychotic features.
 Atypical antipsychotics F. The symptoms are not due to the direct physiological
 Olanzapine effects of a substance (eg. a drug of abuse, a medication) or
 Rosperidone a general medical condition (eg. hyperthyroidism).
 Maniclike episodes that are clearly caused by somatic
MANIC DISORDER – BIPOLAR I antidepressant tretment (medication, electroconvulsive
therapy, light therapy) should not count count toward a
DSM-IV-TR Diagnostic Criteria for Manic Episode diagnosis of bipolar I disorder.

A. A distinct period of abnormally and persistently elevated, Main differences between manic and hypomanic:
expansive, or irritable mood, lasting at least 1 week (or any Manic Hypomanic
duration if hospitalization is necessary) Duration 1 week 4 days
B. During the period of mood disturbance, three or more of Symptom severity  
the following symptoms have persisted (four of the mood Functioning affected not affected
is only irritable) and have been present to a significant Psychotic features  -
degree:
i. inflated self-esteem or grandiosity
MIXED EPISODE
 feeling niya bidang bida siya, walang magaling kundi
sarili niya. siya lang ang tama – over confident
ii. decreased need for sleep (eg. feels rested after only 3 DSM-IV-TR Diagnostic Criteria for Mixed Episode
hours of sleep)
A. The criteria are met for a manic episode and for a major
iii. more talkative than usual or pressure to keep talking
depressive episode (except for duration) nearly every day
during at least 1 week.
B. The mood disturbance is sufficiently secere to cause
marked impairment in occupational functioning or in usual
social activities or relationships with others, or to
necessitate hospitalization to prevent harm to self or SUMMARY
others, or there are psychotic features.
C. The symptoms are not due to the direct physiological Episode Disorder
effects of a substance (eg. a drug of abuse, a medication) or Major depressive Major depressive
a general medical condition (eg. hyperthyroidism). episode disorder; single
 Maniclike episodes that are clearly caused by somatic
antidepressant tretment (medication, electroconvulsive episode
therapy, light therapy) should not count count toward a Major depressive Major depressive
diagnosis of bipolar I disorder.
episode + major disorder; recurrent
CYCLOTHYMIC EPISODE depressive episode
DSM-IV-TR Diagnostic Criteria for Cyclothymic Episode
Major depressive Manic-depressive
episode + manic/mixed disorder Type I/Bipolar
A. For at least 2 years, the presence of numerous periods
with hypomanic symptoms and numerous periods with
episode I
depressive symptoms that do not meet criteria for a major Manic/mixed Manic-depressive
depressive episode. In children and adolescents, the duration disorder Type I/Bipolar
must be at least 1 year.
B. During the above 2-year period, the person has not been I
without symptoms for more than 2 months. Major depressive Manic-depressive
C. No major depressive episode, manic episode, or mixed episode + hypomanic disorder Type
episode has been present during the first two years of the
disturbance. episode II/Bipolar II
D. The symptoms are not better accounted for by Chronic subsyndromal Dysthymic disorder
schizoaffective disorder and are not superimposed on depression
schizophrenia, schizophreniform disorder, delusional
disorder, or psychotic disorder not otherwise specified. Chronic fluctuation Cyclothymic disorder
E. The esymptomscause marked impairment in occupational, between subsyndromal
social, or other important areas of functioning. depression &
F. The symptoms are not due to the direct physiological
effects of a substance (eg. a drug of abuse, a medication) or hypomania
a general medical condition (eg. hyperthyroidism).

RAPID CYCLING
SAMPLE QUIZ
DSM-IV-TR Diagnostic Criteria for Rapid-cycling Specifier ___1. DSM-IV-TR diagnostic criteria for manic episode include the ff:
a. duration of at least 4 days
A. With rapid cycling (can be applied to bipolar I disorder or b. symtoms are not severe enough to cause impairment in
bipolar II disorder) social or occupational functioning
B. At least 4 episodes of a mood disturbance in the previous c. elevated, expansive, or irritable mood
d. all of the above
12 months that meet criteria for a major depressive,
___2. Neurotransmitter commonly associated with depression
manic, mixed, or hypomanic episode. a. dopamine c. GABA
b. norepinephrine d. serotonin
COMPARISON OF THE 5 BIPOLAR DISORDERS: ___3. which of the ff. is a trucyclic antidepressant
Epidemiology_ a. venlafaxine c. fluoxetine
b. imipramine d. mirtazapine
 Bipolar I is less common than MDD ___4. Which of the ff. factors would mean a poor prognosis for a
 lifetime prevalence: Bipolar I patient?
Bipolar I 0.4 – 1.6 % a. female gender c. few suicidal thoughts
Bipolar II 0.5 % b. advanced age of onset d. depressive features
Cyclothymic 0.4 – 1.0 % ___5. Effective blood level range of lithium
a. 0.4 – 0.8 mEq/L c. 1.2 – 1.6 mEq/L
Rapid Cycling 5 – 15 % b. 1.5 – 1.2 mEq/L d. 1.6 – 2.0 mEq/L
 gender prevalence ___6. According to thr depression guideline panel, which of the ff. is a
Bipolar I M=F risk factor for depression?
MDD M<F a. comorbid medical illness c. no prior hx of depression
Manic episode M>F b. onset after 40y d. all of the above
___7. life event most associated with depression
Rapid Cycling M<F a. losing a parent after 11y
 when manic episodes occur in women, more likely it b. losing a spouse bedore 40y
is of the mixed type c. losing a parent before 11y
d. losing a sibling after 7y
___8. Criteria for rapid cycling Bipolar I
a. 2episodes in 12months c. 2episodes in 6months
b. 4episodes in 12months d. 4 episodes in 6 months
___9. most common mood disorder reported
a. MDD
b. Bipolar disorder
c. Dysthymic disorder
d. Cyclothymic disorder
___10. If MDD and Hypomanic episode is present, diagnosis?
a. Cyclothymic disorder
b. Mixed episode
c. Bipolar I disorder
d. Bipolar II disorder

Answers: CDBDBACBAD
SUMMARY