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Mood disorders, Psych II

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  • 1. MOOD DISORDERS HYACINTH C. MANOOD, MD, DPBP
  • 2.
    • Mood is a pervasive and sustained feeling tone that is experienced internally and that influences a person's behavior and perception of the world.
    • Affect is the external expression of mood.
  • 3.
    • A syndrome consisting of a cluster of signs and symptoms sustained over weeks to months, which represent a marked departure from a person’s functioning, and tend to recur , often in periodic or cyclical fashion.
  • 4.
    • MAJOR DEPRESSIVE DISORDERS – major depressive episodes only; unipolar depression
    • BIPOLAR 1 DISORDER – both manic and depressive episodes or manic episodes alone ( unipolar, pure or euphoric mania)
    • BIPOLAR 2 DISORDER – both hypomanic and depressive episodes
  • 5.
    • DYSTHYMIC DISORDER – at least 2 years of depressed mood that is not severe enough to fit the diagnosis of MDD
    • CYCLOTHYMIC DISORDER – at least 2 years of hypomanic symptoms
  • 6. MOOD DISORDER LIFETIME PREVALENCE Major Depressive Disorder Bipolar I disorder Bipolar II disorder Dysthymia Cyclothymia F = 10 – 25% M = 5 – 12% 0.4 – 1.6% 0.5 6% 0.4 – 1.0%
  • 7.
    • twofold greater prevalence of major depressive disorder in women than in men.
    • bipolar I disorder has an equal prevalence among men and women.
    • Manic episodes are more common in men, and depressive episodes are more common in women
  • 8.
    • onset of bipolar I disorder is earlier than that of major depressive disorder
    • mean age of 30 for bipolar I disorder ; mean age of onset for major depressive disorder is about 40 years
    • most often in persons without close interpersonal relationships or in those who are divorced or separated
  • 9.
    • higher than average incidence of bipolar I disorder is found among the upper socioeconomic groups;
    • increased risk of having one or more additional comorbid Axis I disorders - alcohol abuse or dependence, panic disorder, obsessive-compulsive disorder (OCD), and social anxiety disorder
    • Comorbid substance use disorders and anxiety disorders worsen the prognosis of the illness and markedly increase the risk of suicide
  • 10. ETIOLOGY
    • Biological Factors
    • A. Biogenic Amines
    • NOREPINEPHRINE
    • - downregulation or decreased sensitivity of ß-adrenergic receptors ; presynaptic ß2- receptors
    • SEROTONIN
    • - most commonly associated with depression
    • - depletion of serotonin may precipitate depression
  • 11.
    • 3. DOPAMINE
    • - reduced in depression; increased in mania; D1 receptors and mesolimbic dopamine pathway.
    • 4. OTHERS
    • - Abnormal levels of choline
    • - Reductions of GABA
    • - G proteins or other second messengers.
    • - Hypercortisolema
  • 12.
    • 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).
    • - Decreased CSF somatostatin levels have been reported in depression, and increased levels have been observed in mania.
  • 13.
    • B. Alterations of Sleep Neurophysiology
    • (1) an increase in nocturnal awakenings,
    • (2) a reduction in total sleep time,
    • (3) increased phasic rapid eye movement (REM) sleep,
    • (4) increased core body temperature
    • - reduced REM latency
  • 14.
    • KINDLING
    • - the electrophysical process in which repeated subthreshold stimulation of a neuron eventually generates an action potential; “kindling in the temporal lobes”;
    • NEUROANATOMY:
    • - limbic system, basal ganglia and the hypothalamus
  • 15.
    • C. Genetic
    • - if one parent has a mood disorder, a child will have a risk of between 10 and 25 percent for mood disorder.
  • 16.
    • II. 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
  • 17.
    • 3. Cognitive Theory
    • Aaron Beck postulated a cognitive triad of depression that consists of :
    • (1) views about the self : a negative self-precept;
    • (2) about the environment: a tendency to experience the world as hostile and demanding, and
    • (3) about the future : the expectation of suffering and failure.
  • 18.
    • 4. Learned Helplessness
    • - internal causal explanations are thought to produce a loss of self-esteem after adverse external events.
    • - cognitive motivational deficit and emotional deficit
  • 19. DIAGNOSIS
    • DSM IV – TR CRITERIA
    • Mood changes
    • Specified period of time
    • Change in activity level, cognitive abilities, and vegetative functions;
    • Impaired interpersonal, social and occupational functioning
    • Exclusion criteria
  • 20. Major Depressive Episode
    • Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) or (2):
    • 1. depressed mood most of the day, nearly everyday
    • 2. markedly diminished interest or pleasure
    • 3. significant weight loss when not dieting or weight gain, or a decrease or increase in appetite nearly everyday.
    • 4. insomnia or hypersomnia
    • 5. psychomotor agitation or retardation
    • 6. fatigue or loss of energy
    • 7. feelings of worthlessness or excessive or inappropriate guilt
    • 8. diminished ability to think or concentrate, or indecisiveness
    • 9. recurrent thoughts of death, recurrent suicidal ideations w/o a specific plan, suicide attempt, or spedific plan for committing suicide
    • .
  • 21.
    • B. The symptoms do not meet criteria for a mixed episode.
    • C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
    • D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
    • E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation
  • 22. Manic Episode
    • A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
    • B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree :
    • 1. inflated self-esteem or grandiosity;
    • 2. decreased need for sleep;
    • 3. more talkative than usual or pressure to keep talking ;
    • 4. flight of ideas or a subjective experience that thoughts are racing;
  • 23.
    • 5. distractability
    • 6. increase in goal – directed activities or psychomotor agitation;
    • 7. excessive involvement in pleasurable activities that have a high potential for painful consequences.
    • C. The symptoms do not meet the criteria for a mixed episode.
    • D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization
    • E. The symptoms are not due to the direct physiological effects of a substance or a general medical condition.
  • 24. Hypomanic Episode
    • A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days , that is clearly different from the usual non-depressed mood.
    • B. During the period of mood disturbance, three (or more) of the manic symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
    • C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
  • 25.
    • D. The disturbance in mood and the change in functioning are observable by others.
    • E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
    • F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition
  • 26. MIXED EPISODE
    • The criteria are met both for a manic episode and for a major depressive episode nearly every day during at least a 1-week period.
    • The mood disturbance is sufficiently severe to cause a marked impairment in occupational functioning or in usual social activities and relationships with others, or to necessitate hospitalization;
    • The symptoms are not due to the direct physiological effects of a substance or a general medical condition.
  • 27. MAJOR DEPRESSIVE DISORDER
    • If single episode – presence of a single MDE;
    • If recurrent – 2 or more MDE’s.
    • B. The MDE is not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorders NOS;
    • C. There has never been a manic episode, a mixed episode or a hypomanic episode.
  • 28. BIPOLAR I DISORDER(single manic episode)
    • Presence of only one manic episode and no past MDE.
    • The manic episode is not better accounted for by schizoaffective disorder, and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorders NOS;
  • 29. BIPOLAR I DISORDER (most recent episode ________)
    • Currently or most recently in a ________ episode.
    • There has previously been at least one of the other episodes.
    • The mood episodes in A and B are not better accounted for by schizoaffective disorder, and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorders NOS;
  • 30. BIPOLAR II DISORDER
    • Presence or history on one or more MDE.
    • Presence or history of at least one hypomanic episode.
    • There has never been a manic or mixed episode.
    • The mood episodes in A and B are not better accounted for by schizoaffective disorder, and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorders NOS;
    • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • 31. DSM-IV-TR Diagnostic Criteria for Dysthymic Disorder
    • Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note : In children and adolescents, mood can be irritable and duration must be at least 1 year.
    • Presence, while depressed, of two (or more) of the following:
      • poor appetite or overeating
      • insomnia or hypersomnia
      • low energy or fatigue
      • low self-esteem
      • poor concentration or difficulty making decisions
      • feelings of hopelessness
  • 32.
    • During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
    • No major depressive episode has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic major depressive disorder, or major depressive disorder, in partial remission
  • 33.
    • There has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria have never been met for cyclothymic disorder.
    • The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as schizophrenia or delusional disorder.
    • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
    • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • 34. DSM-IV-TR Diagnostic Criteria for Cyclothymic Disorder
    • For at least 2 years, the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. Note: In children and adolescents, the duration must be at least 1 year.
    • During the above 2-year period (1 year in children and adolescents), the person has not been without the symptoms in Criterion A for more than 2 months at a time.
  • 35.
    • No major depressive episode, manic episode, or mixed episode has been present during the first 2 years of the disturbance. Note: After the initial 2 years (1 year in children and adolescents) of cyclothymic disorder, there may be superimposed manic or mixed episodes (in which case both bipolar I disorder and cyclothymic disorder may be diagnosed) or major depressive episodes (in which case both bipolar II disorder and cyclothymic disorder may be diagnosed).
    • The symptoms in Criterion A are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.
    • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).
    • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • 36. TREATMENT
  • 37. GOALS
    • Patient’s safety must be guaranteed.
    • Complete diagnostic evaluation
    • Treatment plan addressing not just immediate symptoms but patient’s prospective well-being.
  • 38.
    • Hospitalization
      • The need for diagnostic procedures
      • The risk for suicide or homicide
      • Grossly reduced ability to get food and shelter
      • History of rapidly progressing symptoms
      • Rupture of patient’s usual support system
  • 39.
    • II. Psychosocial Therapy
    • Cognitive Therapy
    • Interpersonal Therapy
    • Behavior Therapy
    • Psychoanatically-oriented Therapy
    • Family Therapy
  • 40.
    • III. Pharmacotherapy
    • Major Depressive Disorder
    • - MAOI’s, TCAC’s, SSRI’s, SNRI’s
    • B. Bipolar Disorders
    • - Lithium, anticonvulsants, antipsychotics