Educationals

Insomnia and loss of appetite is reported almost by all the patients during their depressive episode though some patients may have hypersomnia and increased appetite. Patients wake up from sleep during the early hours of the day at around 4.00 a.m. or 5.00 a.m., but they just don't feel like getting out of bed. They don't feel fresh and energetic on waking. They may remain in bed just lying down for a couple of hours or wake up other members of the family when they are agitated. Along with loss of appetite some of the patients also complain that they do not relish good food during depressive phase. If the depression continues untreated for some length of time, patients may have substantial weight loss or rarely, weight gain, if there is an increase in appetite.Similarly they don't enjoy indulgence in sexual activities and frequency of such relationships markedly decreases. Some patients also complain of loss of erection or only partial erection.

Delusions and hallucinations

A 40 year old female attempted suicide as she felt that she had committed a great sin when she was 20 years old by refusing to visit the temple with her family members-a delusion of guilt. In rare cases, one may come across a depressed patient who has a delusion of poverty or nihilistic delusions. A 50 year old patient would not allow anyone to switch on lights or fans in the house, would insist on preparing only one item for lunch and dinner and would get angry if anything was bought for the house as he had developed a delusion of poverty.

In severe depression, patients may hear intermittent voices passing indecent comments about them and asking them to put an end to their lives.

COURSE

Manic depressive disorder is more identified by it's longitudinal course than by the individual episodes.
As mentioned earlier, an individual may get his first episode between the age of 20 to 40 years. It may be an episode of mania or depression. The second episode may occur after 6-8 years. Gradually, as the disorder progresses, the interval between the two episodes decreases while severity and duration of each episode increases. Some patients may get mixed symptoms of mania and depression during the episode. When patients get four or more episodes in a year, it is considered as "rapid cycling". About 15 of patients develop rapid cycling. When the patient gets very frequent mood changes over a period of few days or even over a period of few hours in a day, it is called as "ultra-rapid cylcing" and "ultradian mood alternations".

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

The requisite for the diagnosis of manic depressive disorder is the episodes of mania. During the first episode of mania one may have to keep in mind the differential diagnosis of acute psychotic episode or brief psychotic episode or schizophrenia. The longitudinal course of recurrent episodes of mania and/or depression at an interval of couple of years with more or less complete recovery between the episodes, will confirm the diagnosis of manic depressive disorder. Recurrent episodes of schizophrenia with some manic or depressive symptoms and episodes of schizoaffective disorder may be difficult to differentiate from manic depressive disorder.

Manic or depressive symptoms may be transiently seen in patients receiving certain drugs like steroids, contraceptive pills, anti- hypertensives etc. These symptoms are expected to remit once these drugs are discontinued.

Patients having organic mental disorders like neurosyphilis, cerebrovascular accident, space occupying lesion, dementia and hypothyroidism may also present with manic or depressive symptoms. In these conditions, other associated symptoms like memory impairment, and neurological deficits may help us to differentiate them from manic depressive disorders.