He typically feels worse in the morning, and the mood eases slightly as the day progresses. He cannot respond to company or environmental changes and shows little interest in outside events. He withdraws from social interaction, has difficulty concentrating, and experiences a distressing inability to respond emotionally to those nearest to him. Work performance and productivity are impaired, reflecting the patients underlying vacillation and lack of drive. Early waking, loss of appetite and weight (20 lb or more), and diminished libido are common. Psychomotor retardation, manifested as slowing of speech and movement, is a significant central feature. Somatic complaints such as a sense of fatigue or pressure in the head or chest, heaviness of the limbs, or constipation may give rise to hypochondriacal concern and may mask the depression with anxiety and agitation. In the elderly, hypochondriacal preoccupations are prominent and often associated with considerable anxiety and depression.
The patient may frequently express ideas of guilt and self-reproach, commonly relating to past trivial misdemeanors. More severe cases may suffer delusions with themes of wickedness, hopelessness, persecution, or bodily decay. The risk of suicide is considerable in these patients and is greatest either in the early stages of the illness or during recovery, when psychomotor retardation and indecisiveness are less marked. Tragically, the patient may murder those closest to him (and then attempt suicide himself), in the belief that he will spare his loved ones a life of misery and despair.
Manic phase (mania):
Pathologic elevation of mood is less common than depression. Half the patients are depressed for a few days in the prodromal period, but the depression is rapidly superseded by an apparent sense of well-being and heightened self-confidence, and increased energy, accompanied by over activity, disinhibitation, and excessive garrulity. The patient's gaiety is infectious but may suddenly disappear and be replaced by hostility and resentment if his views are challenged or his grandiose schemes are hindered. He may commonly make unwarranted or tactless remarks of a personal nature, querulous and paranoid complaints, and inapproiate sexual advances; these and other actions due to increased assertiveness, distractibility, and disturbed sense of judgment may seriously prejudice his career and social relationships. The clinical picture is colored by the patients own personality, many traits of which may have previously lain dormant are now thrown into stark relief, often baffling those who had thought they had new him well. In later stages paranoid and grandiose ideas escalate into delusional convictions, and insight is completely lost. The duration of sleep is shorted in the manic phase, and neglect of food intake and physical over activity lead to exhaustion. After the manic swing has subsided, two thirds of the patients enter a depressive phase with a small risk of suicide.
Hypomania is a milder and more common than mania. The mood elevation is moderate and accompanied by over activity, distractibility, heightened energy, and irritability, but the flights of ideas or delusional convictions found in fully developed mania are absent.
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