The proportion of patients who develop a depressive episode and then go on to develop an episode of mania within 10 years is approximately:
B. In community studies, 1 in 10 patients who begin with a depressive episode go on to develop an episode of mania within 10 years. If the illness begins at a younger age, the switch happens earlier. This rate increases to nearly 50% if severely depressed hospitalized patients are considered. Long-term follow-up studies blinded for severity and number of previous episodes show much lower conversion rates (3.2%). It is known that the majority of bipolar patients, particularly women, begin with depressive episodes. Among hospitalized depressed patients followed up for nearly a decade, 1% a year converted to bipolar I and 0.5% a year converted to bipolar II. However, this conversion rate is less for outpatients with depression. Factors associated with a change of polarity from unipolar to bipolar were younger age, male sex, family history of bipolarity, antidepressant-induced hypomania, hypersomnic and retarded phenomenology, psychotic depression, and a postpartum episode. The mean age at which the switch occurs is 32 years. The average number of previous episodes in those who switch varies between two and four. The huge differences in switch rates probably reflect the severity of the initial depression, the length of follow-up, and the expanding definitions of bipolar II disorder.
Clinical depression and bereavement share many common features.
Which of the following clinical features points to clinical depression rather than normal mourning?
D. Parkes described features that may distinguish normal mourning from depression. Normal mourning is characterized by pangs of grief, angry pining, and anxiety when reminded of the loss, brief hallucinations, somatic symptoms, and identification-related behaviours. The presence of psychomotor retardation, generalized guilt and suicidal thoughts after the first month suggest development of depression.
Which of the following is an early sign of prolonged grief?
C. Clinging behaviour and inordinate pining may be early signs of prolonged grief as described by Parkes. More recently, childhood experiences of early parental death or divorce, sudden or violent death of a loved one, and high levels of dependency on the deceased for a sense of personal well-being are thought to be associated with prolonged grief. Several of these factors suggest the role of attachment insecurity in increasing a person’s vulnerability to complicated bereavement.
The term ‘specifier’ is used when describing psychiatric diagnoses.
Which of the following is correct with regard to this term?
B. Specifiers are extensions to a diagnosis that further clarify the course, severity, or special features of the diagnosis. Note that while subtypes are mutually exclusive and jointly exhaustive patterns of diagnostic description, specifiers merely provide an opportunity to define a more homogeneous sub-grouping based on observable clinical phenomenon. DSM-IV uses specifiers extensively while dealing with mood disorders. These include specifiers of the most recent episode and the longitudinal course. Specifiers of current clinical severity, psychotic features, and remission status are the most commonly used. Other descriptive specifiers include catatonic features, melancholic features, atypical features, and postpartum onset. The longitudinal course specifiers include a seasonal pattern and the presence of rapid cycling. ICD-10 does not use the term ‘specifiers’ separately, although the majority are discussed in the core text.
Which of the following is true with regard to the longitudinal course of bipolar disorder?
C. In any patient with bipolar disorder, the duration of individual mood episodes tends to be relatively stable throughout the course, with mania generally lasting for a shorter time than depression. But the onset may become more rapid with age. The interval from one episode to the next tends to decrease through the course of illness, although some evidence suggests a tendency for the inter-episode intervals to stabilize after approximately fi ve episodes. Patients with seasonal patterns are more commonly of bipolar II subtype than bipolar I. The first episode is more likely to be triggered by life events than later episodes. Ambelas confirmed the strong correlation between stressful life events and first manic admissions; this association weakens as the illness progresses. This is particularly true for younger bipolar patients with mania rather than depression. This is consistent with the hypothesis of kindling phenomenon in bipolar disorders.
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