Mood Disorders Presentation

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Presentation on Mood Disorders: Major Depressive Disorder, Bipolar I Disorder, etc.
Presentation for doctoral program class at Saybrook University, San Francisco. Fall 2009

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  • Also the humors were related to the elements: water, fire, air, earth.
  • "[It was though that each of] The "humours" gave off vapors which ascended to the brain; an individual's personal characteristics (physical, mental, moral) were explained by his or her "temperament," or the state of theat person's "humours." The perfect temperament resulted when no one of these humours dominated. By 1600 it was common to use "humour" as a means of classifying characters; knowledge of the humours is not only important to understanding later medieval work, but essential to interpreting Elizabethan drama“ Body Type: Sanguine = corpulent Choleric = red-haired and thin Phlegmatic = pallid, corpulent Melancholic = sallow (sickly yellowish hue or complexion), thin
  • DSM-V coming out in 2012
  • Major depressive disorder has identifiers based on how many episodes: MDD single episode or MDD recurrent episodes; based on features: MDD with psychotic symptoms; based on onset: post-partum depression. Always rule out medical conditions, substance abuse and medication as possible causes of the symptoms before assigning diagnosis of a mental illness.
  • A history of one or more single depressive episode is needed in order to meet criteria for a Major Depressive Disorder. In addition, five of the nine most common symptoms of a depressive episode are needed to meet criteria for the diagnosis of MDD. These five symptoms (one of the two depressed mood and decreased in pleasurable activities is also needed) must have been present for most of the day, most days a week for a minimum of two consecutive weeks in order to meet DSM-IV-TR criteria for a MDD diagnosis. Other symptoms are: lack of motivation, decreased libido, irritability, isolation, rumination and loss of self-esteem. Before assigning a MDD diagnosis, the clinician must rule out any other causes including medical conditions, substance use or abuse, other mental disorder or medication induced sxs. If the symptomatology presented does not meet criteria for a MDD and other causes have been ruled out, consider Depression NOS (Not Otherwise Specify).
  • Specify: Early onset: before age 21 Late onset: after age 21 Specify: based on the two years of symptoms if Atypical features (does not mean unusual clinical presentation as the term may imply). The essential features of atypical are: -mood reactivity (criterion A) And at least two of the following features (criterion B): Increased appetite or weight gain, hypersomnia -leaden paralysis -long-lasting pattern of extreme sensitivity to perceived interpersonal rejection. These features predominate during the most recent 2 year period of the dysthymic disorder.
  • Reference: DSM-IV-TR
  • Manic management attempt is how this person suffering from bipolar disorder titles this chart. He reports did it for two reasons: 1) to track his upward mood and ask for help if he got too up, 2) to track how much sleep he was getting and medication taking since adecuate sleep is one of the best ways to avoid an upward into the full-blown manic episode. He reports: “This chart expresses some of the ebullience, intensity, and desire to maximize self-actualization that I was going through at the time”. The color coded bars indicate the time he was using every day for tasks he considered important for growth and balance. He gave himself starts to mark when he had accomplished his goals. The chart was also an intent to keep track with his hygiene since it tends to suffer when a person is in a manic state.
  • A manic episode is not a diagnosis, it is a necessary condition for a Bipolar I diagnosis. There are several diagnostic criterion for Bipolar I: Diagnostic criteria for Bipolar I Disorder, Single Manic Episode: A) Presence of only one Manic Episode and no past Major Depressive Episode. Note: Recurrence is defined as either a change in polarity from depression or an interval of at least 2 month without manic symptoms. B) The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. 2) Diagnostic criteria for Bipolar I Disorder, Most Recent Episode Hypomanic A) Currently (or most recently) in a Hypomanic Episode. B) There has previously been at least one Manic Episode or Mixed Episode. C) The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D) The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. 3) Diagnostic Criteria for Bipolar I Disorder, Most Recent Episode Manic. A) Currently (or most recently) in a Manic Episode. B) There has previously been at least one Major Depressive Episode, Manic Episode, or Mixed Episode. C) The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. 4) Diagnostic Criteria for Bipolar I Disorder, Most Recent Episode Mixed. A) Currently (or most recently) in a Mixed Episode. B) There has previously been at least one Major Depressive Episode, Manic Episode, or Mixed Episode. C) The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, or Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. 5) Diagnostic Criteria for Bipolar I Disorder, Most Recent Episode Depressed A) Currently (or most recently) in a Major Depressive Episode. B) There has previously been at least one Manic Episode or Mixed Episode. C) The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. 6) Diagnostic Criteria for Bipolar I Disorder, Most Recent Episode Unspecified. A) Criteria, except for duration, are currently (or most recently) met for a Manic, a Hypomanic, a Mixed, or a Major Depressive Episode. B) There has previously been at least one Manic Episode or Mixed Episode. C) The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D) The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. E) The mood symptoms in Criteria A and B 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 (e.g. hyperthyroidsm).
  • A hypomanic episode is not a diagnosis but a necessary condition for a Bipolar II diagnosis. Diagnostic criteria for Bipolar II disorder: Presence (or history) of one or more Major Depressive Episodes. Presence (or history) of at least one Hypomanic Episode. There has never been a Manic Episode or a Mixed Episode. The mood symptoms in Criteria A and B are not better accounted for Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Need to specify whether the most recent episode has been Hypomanic or Depressed.
  • A hypomanic episode is not a diagnosis but a necessary condition for a Bipolar II diagnosis. Reference: Google image search. Retrieved from: http://www.psychosis-bipolar.com/information-about-psychoses-57.html
  • From DSM-IV-TR
  • Model for the better understanding of the bipolar mood disorder Google Image search. Retrieved from: http://www.psychosis-bipolar.com/information-about-psychoses-57.html
  • Bipolar I disorders are characterized by distinct manias and depressions. The person afflicted had one or several phases lasting at least one week in which the criteria for a mania are fulfilled (ICD-10: F30 and 31)
  • The bipolar II disorder is characterized by less distinct and accordingly shorter lasting manias, the so-called hypomanias, and often serious depressive episodes. This form of the bipolar mood disorder is very important is also very difficult to grasp since in retrospect the hypomanias are often not considered as classifiable as an illness or remembered. (ICD-10: F31.8)
  • “ Rapid Cycling means a quick change of the episodes. In this special form of bipolar mood disorder at least four (or more) episodes of the mania, hypomania or depression occur within twelve months. Three types are distinguished: Rapid cycling (ICD 10: F31.8) At least four phases per year (in ca. 20% of cases). Ultra rapid cycling (ICD 10: F31.8) change of phase within weeks or days, more than four episodes per month. Ultradian cycling (ICD 10: F31.8) Change of phase within one day on more than four days a week. (ICD-10: F31.8)
  • n the mixed episodes the symptoms of mania and depression occur in rapid rotation to each another or exist at the same time. The inhibition (depression) classically moving in the same direction or excitement (mania) of emotional, cognitive and psychomotor processes no longer exist in the mixed states. Thus, for example rapid thought and speech (like in mania) can occur at the same time as the anxious-depressive mood. A mixed state is an extraordinarily multiform, a clinical picture that is partly difficult to diagnose and treat. (ICD-10: F31.6)
  • A weakened form of bipolar mood disorder is the so-called cyclothymia or cyclothymic disorder. In these persons often mood swings of a strong degree of characterization take place continually over a period or at least two years, whereby the criteria for a depression or mania in detail are not fulfilled and which often occur independently of external influences. The transitions are however very fluent so that in people who come into a clinic or outpatients department with the suspected diagnosis cyclothymia often a bipolar (II) disorder can be determined. (ICD-10: F34)
  • Mood Disorders Presentation

    1. 1. Mood Disorders Lucia Merino Psychopathology Class Presentation December 13 th , 2009
    2. 2. The Four Humors Melancholic   moody glum (water) Choleric   hot-tempered Irritable (fire) Sanguine healthy Happy (air) Phlegmatic droopy Slow (earth) Source: https://eee.uci.edu/clients/bjbecker/PlaguesandPeople/humorsb.jpg
    3. 3. The Four Personality Type based on the four humors The humors each had associated physical and mental characteristics; the result was a system that was quite subtle in its capacity for describing types of personality. Source: http://www.kheper.net/topics/typology/four_humours.html Humor Body Substance Produced by Personality Type Sanguine blood liver Amorous, happy, healthy, optimistic, irresponsible Choleric yellow bile spleen Violent, vengeful, irritable, short tempered, ambitious Phlegmatic phlegm lungs Sluggish, pallid, cowardly, droopy, slow, lazy Melancholic Black bile gall bladder Introspective, sentimental, moody, gloomy, gluttonous
    4. 4. The four humors today
    5. 5. From the four humors to Diagnostic Statistical Manual
    6. 6. Since 2000 using DSM-IV-TR
    7. 7. Mood Disorders <ul><li>Unipolar Disorders </li></ul><ul><li>Major Depressive Disorder </li></ul><ul><li>-specify: single, psychotic, post-partum </li></ul><ul><li>Dysthymic Disorder </li></ul><ul><li>Depressive Disorder NOS </li></ul><ul><li>Bipolar Disorders </li></ul><ul><li>Bipolar I Disorder </li></ul><ul><li>Bipolar II Disorder </li></ul><ul><li>Cyclothymic Disorder </li></ul><ul><li>Bipolar Disorder NOS </li></ul>Mood Disorder due to a General Medical Condition Mood Disorder Not Otherwise Specified Substance-Induced Mood Disorder
    8. 8. Mood changes Vegetative symptoms Suicidal Ideation Negative Self-Evaluation Cognitive changes Major Depressive Disorder <ul><li>Major Depressive Episode Symptoms: </li></ul><ul><li>Sad/depressed mood </li></ul><ul><li>Decreased interest in pleasurable activities </li></ul><ul><li>Motoric changes: retardation or agitation </li></ul><ul><li>Sleep changes: too much or too little </li></ul><ul><li>Appetite changes: anxious eating or no eating </li></ul><ul><li>Fatigue or loss of energy </li></ul><ul><li>Cognitive changes: indecisiveness, lack of attention, concentration </li></ul><ul><li>Guilt, worthlessness, hopelessness </li></ul><ul><li>Suicidal ideation (15-20% more likely suicide) </li></ul>
    9. 9. Dysthymic Disorder <ul><li>A. Depressed mood most of the day </li></ul><ul><li>more days than not for at least 2 yrs. </li></ul><ul><li>B. While depressed presence of 2 of: </li></ul><ul><li>(1) poor appetite or overeating </li></ul><ul><li>(2) insomnia or hypersomnia </li></ul><ul><li>(3) low energy or fatigue </li></ul><ul><li>(4) low self-esteem </li></ul><ul><li>(5) poor concentration or undecis </li></ul><ul><li>(6) hopelessness </li></ul><ul><li>C. During the illness two year period </li></ul><ul><li>the person has never been without </li></ul><ul><li>A & B sxs for more than 2 months </li></ul><ul><li>No Major Depressive Episode has been present during the two years of dysthymia. </li></ul><ul><li>There has never been a manic, hypomanic or mixed episode or cyclothymic d/o. </li></ul><ul><li>The disturbance does not occur during the course of a chronic psychotic disorder </li></ul><ul><li>such as schizophrenia or delusional disorder. </li></ul><ul><li>The symptoms are not due to a medical condition or physiological effect of any </li></ul><ul><li>Substances (alcohol, drugs or medications). </li></ul><ul><li>They symptoms cause clinically significant distress or impairment in social, </li></ul><ul><li>occupational, or other important areas of functioning. </li></ul>Photo source: http://i.ehow.com/images/GlobalPhoto/Articles/5472319/391169-main_Full.jpg
    10. 10. Depressive Disorder Not Otherwise Specified <ul><li>The Depressive Disorder NOS category includes disorders with depressive features that do not meet criteria for a MDD, Dysthymic , Adjustment with Depressed Mood, or Adjustment with Mixed Anxiety and Depressed Mood disorder. Sometimes depressive symptoms can present as part of an Anxiety Disorder NOS. </li></ul><ul><li>Examples of Depressive Disorder NOS include: </li></ul><ul><li>Premenstrual dysphoric disorder: </li></ul><ul><li>Minor depressive disorder: </li></ul><ul><li>Recurrent brief depressive disorder: </li></ul><ul><li>Postpsychotic depressive disorder of Schizophrenia: </li></ul><ul><li>A M D Episode superimposed on Delusional D/O, Psychotic NOS, or the active phase of schizophrenia. </li></ul><ul><li>Situations in which the clinician has concluded that a depressive d/o is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced. </li></ul>
    11. 11. Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder Bipolar Disorder NOS Bipolar Disorders
    12. 12. Manic Episode Source: http://farm4.static.flickr.com/3141/2658083689_60c2ff67a0_o.jpg
    13. 13. <ul><li>Symptoms of a Manic Episode </li></ul><ul><li>Elevated Mood </li></ul><ul><li>Inflated Self-esteem or grandiosity </li></ul><ul><li>Decreased need for sleep </li></ul><ul><li>Talkative, pressure to keep talking </li></ul><ul><li>Racing thoughts, flight of ideas </li></ul><ul><li>Distractibility </li></ul><ul><li>Goal directed activity(social, work, sex) </li></ul><ul><li>Psychomotor agitation </li></ul><ul><li>Excessive pleasurable activities </li></ul><ul><li>Poor judgment behavior </li></ul><ul><li>Diagnostic Criteria: </li></ul><ul><li>A distinct period of abnormally and persistently elevated, expansive, or irritable mood, </li></ul><ul><li>lasting at least 1 week (or any duration if hospitalization is necessary) </li></ul><ul><li>B) During the period of mood disturbance, three or more of the symptoms listed have </li></ul><ul><li>persisted (four if the mood is only irritable) and have been present to a significant degree. </li></ul><ul><li>C) The symptoms do not meet criteria for a mixed episode. </li></ul><ul><li>D) The mood disturbance is sufficiently severe to case marked impairment in functioning. </li></ul><ul><li>E) Not due to a medical condition, treatment or substances. </li></ul>Photo source: http://images.dailyradar.com/media/uploads/showhype/photos_large/2008/09/07/robinwilliams.jpg
    14. 14. Case presentation <ul><li>45 year old divorced Caucasian working male sober </li></ul><ul><li>for last 20 yrs –computer programmer. </li></ul><ul><li>Presenting symptoms: </li></ul><ul><li>Sleeping 3-4 hours walking up fully rested </li></ul><ul><li>Writing 2-3 short novels per week (goal directed) </li></ul><ul><li>Racing thoughts – rush of mental energy </li></ul><ul><li>Promiscuous behavior including female therapist </li></ul><ul><li>Poor judgment behavior (i.e. getting $ from ATM </li></ul><ul><li>and giving it out to people in the street, getting on a </li></ul><ul><li>plane to Thailand and spending several months having sex with prostitutes, ex-wife wiring $ </li></ul><ul><li>to stay longer an finally having to bail him out of jail, having robbers and drunks as room </li></ul><ul><li>mates at home and relapsing. </li></ul><ul><li>Showing up in his company party on a skirt with no underwear and flirting with personnel. </li></ul><ul><li>Finally losing job, health, properties, finances and being sent to a nursing home since his </li></ul><ul><li>health severely deteriorated and family were not able to take care of him. His children were </li></ul><ul><li>afraid of him being inappropriate with children, showing up drunk or being aggressive. </li></ul><ul><li>His behavior was grandiose, he would wear lots of native American jewelry he had made, </li></ul><ul><li>colorful beads necklaces, chains with buffalo horns pendant, many rings in his fingers and </li></ul><ul><li>an exuberant big hat with exotic feathers. </li></ul>Picture retrieved from: http://www.hypomanicedge.com/reviews/nyt/nytimesarticle.jpg
    15. 15. <ul><li>Symptoms of a Hypomanic Episode </li></ul><ul><li>Elevated, expansive, or irritable mood </li></ul><ul><li>Inflated Self-esteem or grandiosity </li></ul><ul><li>Decreased need for sleep </li></ul><ul><li>Talkative, pressure to keep talking </li></ul><ul><li>Racing thoughts, flight of ideas </li></ul><ul><li>Distractibility </li></ul><ul><li>Goal directed activity(social, work, sex) </li></ul><ul><li>Psychomotor agitation </li></ul><ul><li>Excessive pleasurable activities </li></ul><ul><li>Poor judgment behavior </li></ul>Diagnostic Criteria: A) A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days , that is different from the usual non-depressed mood. B) During the period of mood disturbance, three or more of the symptoms listed 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 uncharacteristic change in functioning. 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 not due to the physiological effects of substances or medical conditions.
    16. 16. Diagnostic Criteria Cyclothymic Disorder <ul><li>For at least 2 years, the presence of numerous periods with hypomanic symptoms </li></ul><ul><li>and numerous periods with depressive symptoms that do not meet criteria for a MDE. </li></ul><ul><li>During the above 2-year period (1 year in children and adolescents), the person </li></ul><ul><li>has not been without the symptoms in Criterion A for more than 2 months at a time. </li></ul><ul><li>No Major Depressive Episode, Manic Episode, or Mixed Episode has been present </li></ul><ul><li>during the first 2 years of the disturbance. </li></ul><ul><li>The symptoms in Criterion A are not better accounted for by Schizoaffective and are </li></ul><ul><li>not superimposed on Schizophrenia, Schizophreniform, Delusional, or Psychotic NOS. </li></ul><ul><li>Symptoms not due to the effects of substances, mediations or medical conditions. </li></ul><ul><li>F. The symptoms cause clinically significant distress or impairment in functioning. </li></ul>Photo source: http://www.metroactive.com/papers/metro/03.30.00/gifs/bipolar2-0013.jpg
    17. 17. Bipolar Disorder NOS <ul><li>The Bipolar Disorder NOS category includes disorders with bipolar features that do not meet criteria for any specific Bipolar Disorders. Examples are: </li></ul><ul><li>Very rapid alternation (over days) between manic symptoms and depressive symptoms that meet symptom threshold criteria but not minimal duration for Manic, Hypomanic, or Major Depressive Episodes. </li></ul><ul><li>Recurrent Hypomanic Episodes without intercurrent depressive sxs. </li></ul><ul><li>A Manic or Mixed Episode superimposed on Delusional D/O, residual Schizophrenia, or Psychotic D/O NOS. </li></ul><ul><li>Hypomanic Episodes, along with chronic depressive symptoms, that are too infrequent to qualify for a diagnosis of Cyclothymic Disorder. </li></ul><ul><li>Situations in which the clinical has concluded that a Bipolar Disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced. </li></ul>Source: DSM-IV-TR
    18. 18. Summary Graphics Retrieved from: http://journey2balance.files.wordpress.com/2009/10/bipolar_arrow.jpg
    19. 19. Summary Graphics Retrieved from: http://www.thebody.com/content/esp/art6293.html
    20. 20. Bipolar I, II, and Cyclothymic Disorders Retrieved from: http://www.psychosis-bipolar.com/information-about-psychoses-57.html
    21. 26. References Woo, S., & Keatinge, C. (2008) Schizophrenia and other psychotic Disorders (pp.469-532) in Diagnosis and Treatment of Mental Disorders Across the Life Span. Wiley: NJ American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders; Fourth edition; Text Revision; DSM-IV-TR. APA:DC

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