3-16
Subjective: Symptoms
Depression: Loss of pleasure in activities, social isolation and withdrawal, subjective cognitive impairments,
anxiety, worry, excessive guilt, preoccupation with thoughts of death or suicide, insomnia or hypersomnia,
changes in appetite and weight, loss of energy and feelings of helplessness, hopelessness, and worthless-
ness.
Mania: Mood elevation, grandiosity, increased seeking of pleasurable stimuli (hyper-sexuality, spending
money, etc.), intrusiveness, belief in special powers, skills or relationships.
Focused History: When did you start feeling this way, and have you ever felt this way before? (Many people
with depression have had it before.) Are these feelings constant or do they come and go? (Severe depression
is usually ever-present; mood swings are related to personality; mania rarely switches rapidly enough to seem
to “come and go.”) How is your sleep? (Depressed patients complain of poor sleep or too much sleep, but
never feeling rested; manic patients insist they feel ne on very little sleep.) How is your appetite? (often
decreased in depression, but some patients complain of cravings or eating too much in order to feel better)
Can you do your job? (Hypo-manic patients appear to do their job very well [and try to do everyone else’s];
manic and depressed patients have obvious impairment in work functioning.) Do you have thoughts of hurting
yourself or anyone else? (Always, always ask!) What helps you feel better? (Manic patients feel even
better with sex, alcohol or spending money; depressed patients nd that little interests them or helps them
feel better.)
Objective: Signs
Let a patient talk for a few minutes uninterrupted and try to sit quietly and follow where the train of thought
goes. What themes are present? Depressed themes? Grand themes? Are the thoughts connected? Are
there delusions? How severe is the depression—on a scale of 1 to 10.
Using Basic Tools: Normal vitals; manic patients may have slightly elevated pulse and BP.
Mental Status Exam:
Depressed persons appear sad or sometimes worried. They move slowly but may also be agitated,
unable to sit still. Look for hand wringing. A depressed person will often avoid eye contact, preferring
to gaze downward. Depressed persons may have difculty concentrating or completing thoughts. Mental
processes are generally slowed.
Manic persons are happy or irritable. They talk profusely—that is, with pressured speech. Interrupting
them is like trying to stop a freight train. Manic persons can be grandiose—believing they are God,
or simply have grand ideas about how to solve the world’s problems. They are energetic and intrusive.
Sometimes ideas are very loosely connected or hard to follow.
Always ask about suicidal and homicidal ideations, intents or plans.
Both depressed and manic patients may develop xed false beliefs called delusions. This represents
more severe illness.
Assessment:
Differential Diagnosis
Condition Manic Symptoms Depressive Symptoms
Substance Intoxication PCP, LSD, amphetamines, cocaine Barbiturates, benzodiazepines, alcohol,
marijuana
Trauma or Mass lesion Head injury, tumor Head injury, tumor
Endocrine Hyperthyroidism Hypothyroidism
Mental Disorder Bipolar Disorder—a severe illness Major depressive disorder—a severe