MOOD DISORDERS

DJ VIC

HISTORY• HIPPOCRATES (400 B.C.) USED THE TERMS MANIA AND MELANCHOLIA TO

DESCRIBE MENTAL DISTURBANCES

• ROMAN PHYSICIAN (30 A.D.) DESCRIBED MELANCHOLIA AS DEPRESSION CAUSED BY BLACK BILE

• IN 1854, JULES FARLET DESCRIBED A CONDITION CALLED FOLIE CIRCULAIRE: ALTERNATING MOODS OF DEPRESSION AND MANIA

• IN 1899, EMIL KRAEPELIN DESCRIBED MANIC-DEPRESSIVE PSYCHOSIS USING MOST OF THE CRITERIA THAT PSYCHIATRISTS USE NOW

DEFINITIONMOOD : - PERVASIVE AND SUSTAINED

- FEELING THAT IS EXPRESSED INTERNALLY

-THAT INFLUENCES A PERSON’S BEHAVIOUR AND PERCEPTION OF THE WORLD

-DISTINGUISHED FROM AFFECT – IS THE EXTERNAL

EXPRESSION OF MOOD

MOOD DISORDERS :ARE A GROUP OF CLINICAL CONDITIONS CHARACTERISED BY LOSS OF THE SENSE OF CONTROL & A SUBJECTIVE EXPERIENCE OF GREAT DISTRESS.

Elevated mood-Expansiveness-Flight of ideas-Decreased sleep-Grandiose ideas

Depressed mood-Lack of energy /interest-Feelings of guilt-Difficulty in concentration-Loss of appetite-Thoughts of death /suicide

MOOD DISORDERS

UNIPOLAR MOOD DISORDERS

BIPOLAR MOOD DISORDERS

• UNIPOLAR MOOD DISORDER = PATIENT EXPERIENCE ONE OR MORE (DEPRESSION) EPISODES OF LOW MOOD

• MANIA = PATIENT EXPERIENCE ELEVATED MOOD, AND INCREASE IN QUANTITY AND SPEED OF PHYSICAL AND MENTAL ACTIVITY

• BIPOLAR MOOD DISORDER = PATIENT EXPERIENCES BOTH

LOW MOOD (DEPRESSION) AND ABNORMALLY ELEVATED MOOD (HYPOMANIA OR MANIA)

OTHER ADDITIONAL CATEGORIES OF MOOD DISORDERSHYPOMANIA - AN EPISODE OF MANIC SYMPTOMS THAT

DOES NOT MEET THE CRITERIA FOR MANIC EPISODE

CYCLOTHYMIA - DISORDER THAT REPRESENT LESS SEVERE FORMS OF BIPOLAR DISORDER

DYSTHYMIA - DISORDER THAT REPRESENT LESS SEVERE FORMS OF MAJOR DEPRESSION

CLASSIFICATION –ICD 10F30 MANIC EPISODE• F30.0 HYPOMANIA• F30.1 MANIA WITHOUT PSYCHOTIC SYMPTOMS• F30.2 MANIA WITH PSYCHOTIC SYMPTOMS• F30.8 OTHER MANIC EPISODES• F30.9 MANIC EPISODE, UNSPECIFIED

F31 BIPOLAR AFFECTIVE DISORDER• F31.0 BIPOLAR AFFECTIVE DISORDER, CURRENT EPISODE HYPOMANIC• F31.1 BIPOLAR AFFECTIVE DISORDER, CURRENT EPISODE MANIC WITHOUT PSYCHOTIC SYMPTOMS• F31.2 BIPOLAR AFFECTIVE DISORDER, CURRENT EPISODE MANIC WITH PSYCHOTIC SYMPTOMS• F31.3 BIPOLAR AFFCTIVE DISORDER, CURRENT EPISODE MILD OR MODERATE DEPRESSION• F31.4 BIPOLAR AFFECTIVE DISORDER, CURRENT EPISODE SEVERE DEPRESSION WITHOUT PSYCHOTIC

SYMPTOMS• F31.5 BIPOLAR AFFECTIVE DISORDER, CURRENT EPISODE SEVERE DEPRESSION WITH PSYCHOTIC

SYMPTOMS • F31.6 BIPOLAR AFFECTIVE DISORDER, CURRENT EPISODE MIXED• F31.7 BIPOLAR AFFECTIVE DISORDER, CURRENTLY IN REMISSION • F31.8 OTHER BIPOLAR AFFECTIVE DISORDERS• F31.9 BIPOLAR AFFECTIVE DISORDER, UNSPECIFIED

F32 DEPRESSIVE EPISODE

• F32.0 MILD DEPRESSIVE EPISODE• F32.1 MODERATE DEPRESSIVE EPISODE• F32.2 SEVERE DEPRESSIVE EPISODE WITHOUT PSYCHOTIC SYMPTOMS• F32.3 SEVERE DEPRESSIVE EPISODE WITH PSYCHOTIC SYMPTOMS• F32.8 OTHER DEPRESSIVE EPISODES• F32.9 DEPRESSIVE EPISODE, UNSPECIFIED

F33 RECURRENT DEPRESSIVE DISORDER

• F33.0 RECURRENT DEPRESSIVE DISORDER, CURRENT EPISODE MILD• F33.1 RECURRENT DEPRESSIVE DISORDER, CURRENT EPISODE MODERATE• F33.2 RECURRENT DEPRESSIVE DISORDER, CURRENT EPISODE SEVERE WITHOUT PSYCHOTIC SYMPTOMS• F33.3 RECURRENT DEPRESSIVE DISORDER, CURRENT EPISODE SEVERE WITH PSYCHOTIC SYMPTOMS• F33.4 RECURRENT DEPRESSIVE DISORDER, CURRENTLY IN REMISSION• F33.8 OTHER RECURRENT DEPRESSIVE DISORDERS• F33.9 RECURRENT DEPRESSIVE DISORDER, UNSPECIFIED

F34 PERSISTENT MOOD [AFFECTIVE] DISORDERS

• F34.0 CYCLOTHYMIA• F34.1 DYSTHYMIA• F34.8 OTHER PERSISTENT MOOD [AFFECTIVE] DISORDERS• F34.9 PERSISTENT MOOD [AFFECTIVE] DISORDER, UNSPECIFIED

F38 OTHER MOOD [AFFECTIVE] DISORDERS

• F38.0 OTHER SINGLE MOOD [ AFFECTIVE ] DISORDERS• F38.1 OTHER RECURRENT MOOD [ AFFECTIVE ] DISORDERS • F38.8 OTHER SPECIFIED MOOD [AFFECTIVE] DISORDERS

F39 UNSPECIFIED MOOD [ AFFECTIVE ] DISORDER

CLASSIFICATION – DSM 5MOOD DISORDERS

• MAJOR DEPRESSIVE EPISODE• MANIC EPISODE • HYPOMANIC EPISODE

DEPRESSIVE DISORDERS

• MAJOR DEPRESSIVE DISORDER• PERSISTENT DEPRESSIVE DISORDER• DISRUPTIVE MOOD REGULATION (CHILDREN’S TEMPER TANTRUMS)• PREMENSTRUAL DYSPHORIC DISORDER• DEPRESSIVE DISORDER DUE TO ANOTHER MEDICAL CONDITION• SUBSTANCE/MEDICATION-INDUCED MOOD DISORDER• OTHER SPECIFIED, OR UNSPECIFIED DEPRESSIVE DISORDER

BIPOLAR AND RELATED DISORDERS

• BIPOLAR I DISORDER• BIPOLAR II DISORDER• CYCLOTHYMIC DISORDER

• SUBSTANCE/MEDICATION-INDUCED BIPOLAR DISORDER• BIPOLAR DISORDER DUE TO ANOTHER MEDICAL CONDITION • OTHER SPECIFIED OR UNSPECIFIED BIPOLAR DISORDER

DEPRESSION• IS A STATE OF (PERSISTENT AND PERVASIVE) LOW MOOD WITH INTENSE

DISLIKE TO ACTIVITY OR APATHY THAT CAN AFFECT A PERSON'S THOUGHTS, BEHAVIOUR, FEELINGS AND SENSE OF WELL-BEING.

• A PATIENT WITH DEPRESSION MAY EXPERIENCE VARIOUS SYMPTOMS SUCH AS LOSE INTEREST IN ACTIVITIES THAT WERE ONCE PLEASURABLE, EXPERIENCE LOSS OF APPETITE OR OVEREATING, HAVE PROBLEMS CONCENTRATING, REMEMBERING DETAILS OR MAKING DECISIONS, EXPERIENCE RELATIONSHIP DIFFICULTIES AND MAY CONTEMPLATE, ATTEMPT OR COMMIT SUICIDE, INSOMNIA, EXCESSIVE SLEEPING, FATIGUE, ACHES, PAINS, DIGESTIVE PROBLEMS OR REDUCED ENERGY MAY ALSO BE PRESENT.

• THE SYMPTOMS CAN BE DIVIDED IN THREE DIFFERENT GROUPS

SYMPTOMS OF DEPRESSION

CORE SYMPTOMSLOW MOOD, LOSS OF INTEREST IN

ENJOYMENT

PSYCHOLOGICAL SYMPTOMS

POOR CONCERNTRATION, POOR SELF-ESTEEM, INAPPROPRIATE GUILT, PESSIMISM, RECURRING

THOUGHTS OF DEATH OR SUICIDE

PHYSICAL SYMPTOMSSLEEP DISTURBANCE WITH OFTEN EARLY MORING WAKING, FATIGUE, LOSS OF APPETITE AND WEIGHT

LOSS, LOSS OF LIBIDO, ANHEDONIA, AGITATION OR RETARDATION

DEPRESSIVE EPISODE• HAS THREE DIFFERENT SEVERITY – MILD, MODERATE AND SEVERE

• FOR ALL THE THREE GRADES OF SEVERITY THE INDIVIDUAL SUFFERS FROM THE COMMON SYMPTOMS SUCH AS DEPRESSED MOOD, LOSS OF INTEREST AND ENJOYMENT AND REDUCED ENERGY LEADING TO FATIGABILITY AND DIMINISHED ACTIVITY.

• DESPITE THE SEVERITY, THE DURATION OF THE SYMPTOMS SHOULD BE PRESENT AT LEAST FOR 2 WEEKS ( REQUIRED FOR THE DIAGNOSIS)

• HOW TO DIAGNOSE MILD, MODERATE AND SEVERE DEPRESSIVE EPISODE?

ACCORDING TO DSM-5, FOR MAJOR DEPRESSIVE EPISODE TO BE MADE, FIVE OR MORE SYMPTOMS OF DEPRESSION MUST HAVE BEEN PRESENT FOR A PERIOD OF AT LEAST 2 WEEKS OR MORE.AT LEAST ONE OF THE SYMPTOMS MUST BE EITHER DEPRESSED MOOD OR LOSS OF INTEREST OR PLEASURE, AND THE SYMPTOMS MUST BE ASSOCIATED WITH SIGNIFICANT DISTRESS OR IMPAIRMENT.

A DIAGNOSIS OF MAJOR DEPRESSIVE DISORDER, EITHER SINGLE EPISODE OR RECURRENT, CAN ONLY BE MADE IN THE ABSENCE OF MANIC OR HYPOMANIC EPISODES

MANIA• IS A STATE OF ABNORMALLY ELEVATED AROUSAL, AFFECT, AND ENERGY LEVEL, OR A

STATE OF HEIGHTENED OVERALL ACTIVATION WITH ENHANCED AFFECTIVE EXPRESSION TOGETHER WITH LABILITY OF AFFECT

MANIC EPISODE

• IS A DISTINCT PERIOD • OF AN ABNORMALLY AND PERSISTENTLY ELEVATED, EXPANSIVE, OR IRRITABLE MOOD • LASTING FOR AT LEAST 1 WEEK, (OR LESS - IF A PATIENT MUST BE HOSPITALIZED )

HYPOMANIC EPISODE

• LASTS AT LEAST 4 DAYS• SIMILAR TO A MANIC EPISODE • EXCEPT THAT IT IS NOT SUFFICIENTLY SEVERE TO CAUSE IMPAIRMENT IN SOCIAL OR

OCCUPATIONAL FUNCTIONING• NO PSYCHOTIC FEATURES ARE PRESENT.

BOTH ARE ASSOCIATED WITH• INFLATED SELF-ESTEEM OR GRANDIOSITY• DECREASED NEED FOR SLEEP,• DISTRACTIBILITY• GREAT PHYSICAL AND MENTAL ACTIVITY• OVER INVOLVEMENT IN PLEASURABLE BEHAVIOUR• MORE TALKATIVE THAN USUAL OR PRESSURE TO KEEP TALKING• FLIGHTS OF IDEAS OR SUBJECTIVE EXPERIENCE THAT THOUGHTS ARE RACING • INCREASE IN GOAL-DIRECTED ACTIVITY OR PSYCHOMOTOR AGITATION

ICD-10 CRITERIAHYPOMANIA

• LESSER DEGREE OF MANIA• PERSISTENT MILD ELEVATION OF MOOD- EUPHORIA• MARKED FEELINGS OF WELL BEING AND EFFICIENCY• INCREASED ENERGY AND ACTIVITY• DECREASED NEED FOR SLEEP• INCREASED SOCIABILITY AND TALKATIVENESS• NOT LEADING TO SEVERE DISRUPTION OF WORK OR SOCIAL REJECTION• PRESENT FOR SEVERAL DAYS ON END (4 DAYS)

MANIA WITHOUT PSYCHOTIC SYMPTOMS

• LAST FOR AT LEAST 1WEEK• SEVERE ENOUGH TO DISRUPT ORDINARY WORK AND SOCIAL ACTIVITIES• ELATED MOOD• INCREASED ENERGY WITH OVER ACTIVITY• PRESSURED SPEECH• DECREASED NEED FOR SLEEP• MARKED DISTRACTIBILITY• DISINHIBITED, OVERSPENDING• EXPANSIVE IDEAS

MANIA WITH PSYCHOTIC SYMPTOMS

• MORE SEVERE FORM• DELUSIONS- GRANDIOSE AND/OR PERSECUTORY• PERCEPTUAL ABNORMALITIES• SEVERE AND SUSTAINED PHYSICAL ACTIVITY, EXCITEMENT• FLIGHT OF IDEAS, INCOHERENCE• IMPAIRED PERSONAL CARE

BIPOLAR MOOD DISORDERSBIPOLAR I DISORDER

• CHARACTERIZED BY THE OCCURRENCE OF AT LEAST ONE MANIC OR MIXED EPISODE MOST OF THE PATIENTS ALSO, SOMETIMES, HAVE ONE OR MORE DEPRESSIVE EPISODES.

MIXED EPISODE

• A PERIOD OF AT LEAST 1 WEEK• BOTH A MANIC EPISODE AND A MAJOR DEPRESSIVE EPISODE OCCUR ALMOST DAILY.

BIPOLAR II DISORDER

• A VARIANT OF BIPOLAR DISORDER• EPISODES OF MAJOR DEPRESSION AND HYPOMANIA (RATHER THAN MANIA)

DYSTHYMIA AND CYCLOTHYMIADYSTHYMIC DISORDER

• AT LEAST 2 YEARS OF DEPRESSED MOOD • NOT SUFFICIENTLY SEVERE TO FIT THE DIAGNOSIS OF MAJOR DEPRESSIVE

EPISODE. CYCLOTHYMIC DISORDER

AT LEAST 2 YEARS OF FREQUENTLY OCCURRING • HYPOMANIC SYMPTOMS CANNOT FIT THE DIAGNOSIS OF MANIC EPISODE • DEPRESSIVE SYMPTOMS THAT CANNOT FIT THE DIAGNOSIS OF MAJOR

DEPRESSIVE EPISODE.

D/DX OF DEPRESSIVE DISORDER• DEPRESSION• DYSTHYMIA • CYCLOTHYMIA• BIPOLAR MOOD DISORDER• MIXED AFFECTIVE STATES• SCHIZOAFFECTIVE DISORDER• SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS, INCLUDING DEPRESSION SUPERIMPOSED UPON SCHIZOPHRENIA, NEGATIVE SYMPTOMS OF SCHIZOPHRENIA, ADVERSE EFFECTS OF ANTIPSYCHOTIC

• ADJUSTMENT DISORDER

• SEASONAL AFFECTIVE DISORDER (SAD)

• POST-TRAUMATIC STRESS DISORDER (PTSD)

• GENERALIZED ANXIETY DISORDER

• OBSESSIVE-COMPULSIVE DISORDER

• EATING DISORDER

ORGANIC DIFFERENTIAL

NEUROLOGICALStroke, Alzheimer’s disease and other Dementias, Parkinson’s disease, Huntington disease, Multiple sclerosis, Epilepsy, intracranial tumors

ENDOCRINECushing’s syndrome, Addison’s disease, Hypothyroidism, Hyperparathyroidism

METABOLIC Iron deficiency, B12 or folate deficiency, Hypercalcaemia, Hypomagnesaemia

INFECTIVEInfluenza, Infections mononucleosis, Hepatitis, HIV/AIDS

NEOPLASTIC Non-metastatic effects of carcinoma

DRUGSL-dopa, steroids, beta-blockers, digoxin,cocaine, amphetamines, opioids, alcohol

D/DX OF MANIA AND BIPOLAR DISORDER• SCIZOAFFECTIVE DISORDER• SCHIZOPHRENIA• PUERPERAL PSYCHOSIS• CYCLOTHYMIA• ATTENTION DEFICIT HYPERACTIVITY DISORDER

ORGANIC DIFFERENTIAL• DRUGS SUCH AS ALCOHOL, ANTI-DEPRESSANT, L-DOPA, STEROIDS. • SLEEP DEPRIVATION• DELIRIUM• BRAIN DISEASE OF THE FRONTAL LOBES SUCH AS DEMENTIA, STROKE,

MULTIPLE SCLEROSIS, TOMOUR, EPILEPSY, AIDS, NEUROSYPHLIS.

• ENDOCRINE DISORDERS SUCH AS HYPERTHYROIDISM, CUSHING’S SYNDROME

• SYSTEMIC LUPUS ERYTHEMATOSUS

EPIDEMIOLOGY • INCIDENCE AND PREVALENCE:

DEPRESSIVE DISORDER – THE LIFETIME INCIDENCE OF DEPRESSIVE DISORDERS IS ABOUT 15% AND POINT PREVALENCE ABOUT 5%

• SEX:WOMEN : MEN = 2:1. (MDD) ; 1:1(BPD)THE HYPOTHESIS REASONING IT :

• HORMONAL DIFFERENCES, • THE EFFECTS OF CHILDBIRTH, • DIFFERING PSYCHOSOCIAL STRESSORS • BEHAVIOURAL MODELS OF LEARNED HELPLESSNESS.

MANIC EPISODES ARE MORE COMMON IN MEN, AND DEPRESSIVE EPISODES ARE MORE COMMON IN WOMEN.

WOMEN• MORE LIKELY THAN MEN TO PRESENT A MIXED PICTURE • HIGHER RATE OF BEING RAPID CYCLERS, DEFINED AS HAVING FOUR

OR MORE MANIC EPISODES IN A 1-YEAR PERIOD.

AGE:• THE MEAN AGE OF ONSET FOR BIPOLAR I DISORDER = 30YRS.

• THE MEAN AGE OF ONSET FOR MAJOR DEPRESSIVE DISORDER = 40 YEARS (50 % BETWEEN 20-50YRS)

• RECENT TREND: INCIDENCE OF MDD - INCREASING IN <20 YEARS OF AGE – (ALCOHOL AND DRUGS OF ABUSE)

MARITAL STATUS• POOR INTERPERSONAL RELATIONSHIPS• DIVORCED OR SEPARATED

SOCIOECONOMIC AND CULTURAL FACTORS• NO CORRELATION FOR MDD• BPD 1 : UPPER SOCIO-ECONOMIC GROUP

COMORBIDITY• MDD : INCREASED RISK OF HAVING ONE OR MORE ADDITIONAL COMORBID

AXIS I DISORDERS.• ALCOHOL ABUSE OR DEPENDENCE, • PANIC DISORDER, • OBSESSIVE COMPULSIVE DISORDER (OCD), • SOCIAL ANXIETY DISORDER.• WORSEN THE PROGNOSIS AND INCREASE - RISK OF SUICIDE

ETIOLOGY1.BIOLOGICAL FACTORS

• NOREPINEPHRINE

- DOWNREGULATION OR DECREASED SENSITIVITY OF ẞ-ADRENERGIC RECEPTORS ; PRESYNAPTIC ẞ2- RECEPTORS

• SEROTONIN

- MOST COMMONLY ASSOCIATED WITH DEPRESSION- DEPLETION OF SEROTONIN MAY PRECIPITATE DEPRESSION

• DOPAMINE-REDUCED IN DEPRESSION; INCREASED IN MANIA; D1 RECEPTORS

AND MESOLIMBIC DOPAMINE PATHWAY.

• OTHERS- ABNORMAL LEVELS OF CHOLINE - REDUCTIONS OF GABA - G PROTEINS OR OTHER SECOND MESSENGERS. - HYPERCORTISOLEMIA (CUSHING’S)- ELEVATED BASAL THYROID-STIMULATING HORMONE (TSH) LEVEL OR AN INCREASED TSH RESPONSE TO A 500-MG INFUSION OF THE HYPOTHALAMIC NEUROPEPTIDE THYROID-RELEASING HORMONE (TRH).

• ALTERATIONS OF SLEEP NEUROPHYSIOLOGY -AN INCREASE IN NOCTURNAL AWAKENINGS,

-A REDUCTION IN TOTAL SLEEP TIME, -INCREASED PHASIC RAPID EYE MOVEMENT (REM) SLEEP,

-INCREASED CORE BODY TEMPERATURE -REDUCED REM LATENCY

• NEUROANATOMY:-LIMBIC SYSTEM, BASAL GANGLIA AND THE HYPOTHALAMUS

• GENETIC - IF ONE PARENT HAS A MOOD DISORDER, A CHILD WILL

HAVE A RISK OF BETWEEN 10% - 25% FOR MOOD DISORDER.

PSYCHOSOCIAL FACTORS 1. LIFE EVENTS AND ENVIRONMENTAL STRESS

-THE LIFE EVENT MOST OFTEN ASSOCIATED WITH DEVELOPMENT OF DEPRESSION IS LOSING A PARENT BEFORE AGE 11.-THE ENVIRONMENTAL STRESSOR MOST OFTEN ASSOCIATED

WITH THE ONSET OF AN EPISODE OF DEPRESSION IS THE LOSS OF A SPOUSE.

2. PERSONALITY FACTORS

-PERSONS WITH CERTAIN PERSONALITY DISORDERS: OCD, HISTRIONIC, AND BORDERLINE, MAY BE AT GREATER

RISK FOR DEPRESSION

3.COGNITIVE THEORY

AARON BECK POSTULATED A COGNITIVE TRIAD OF DEPRESSION THAT CONSISTS OF :

-VIEWS ABOUT THE SELF : A NEGATIVE SELF-PRECEPT;-ABOUT THE ENVIRONMENT: A TENDENCY TO EXPERIENCE THE -

WORLD AS HOSTILE AND DEMANDING, AND-ABOUT THE FUTURE : THE EXPECTATION OF SUFFERING AND

FAILURE.

4.HELPLESSNESS

-INTERNAL CAUSAL EXPLANATIONS ARE THOUGHT TO PRODUCE A LOSS OF SELF ESTEEM AFTER ADVERSE EXTERNAL EVENTS.

-COGNITIVE MOTIVATIONAL DEFICIT AND EMOTIONAL DEFICIT

TREATMENTAIM

PATIENT’S SAFETY MUST BE GUARANTEED.

COMPLETE DIAGNOSTIC EVALUATION

TREATMENT PLAN ADDRESSING NOT JUST IMMEDIATE SYMPTOMS BUT PATIENT’S PROSPECTIVE WELL-

BEING

HOSPITALIZATION

• THE NEED FOR DIAGNOSTIC PROCEDURES

• THE RISK FOR SUICIDE OR HOMICIDE

• HISTORY OF RAPIDLY PROGRESSING SYMPTOMS

• PATIENT’S USUAL SUPPORT SYSTEM INTERRUPTED(RESPITE)

PSYCHOSOCIAL THERAPY

PHARMACOTHERAPYDEPRESSIVE DISORDER

- MAOI’S, TCA’S, SSRI’S, SNRI’S

BIPOLAR DISORDERS- LITHIUM, ANTICONVULSANTS, ANTIPSYCHOTICS

THANK YOU

RESOURCES-DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FIFTH EDITION (DSM-5). AMERICAN PSYCHIATRIC ASSOCIATION. 2013.-SALMANS, SANDRA (1997). DEPRESSION: QUESTIONS YOU HAVE – ANSWERS YOU NEED. PEOPLE'S MEDICAL SOCIETY. ISBN 978-1-882606-14-6.-ICD-10 CLASSIFICATION OF MENTAL AND BEHAVIOURAL DISORDERS-NEEL BURTON THIRD EDITION, PSYCHIATRY ISBN 978 0 9929127 4 1-OXFORD HANDBOOK OF PSYCHIATRY THIRD EDITION- HTTPS://WWW.NCBI.NLM.NIH.GOV/BOOKS/NBK10847/