description of 2 major mood disorders : depression ,mania ,bipolar . their signs ,symptoms ,icd and dsm criteria

1. MOOD DISORDERS
Signs and Symptoms
-Sakshi Maheshwari
M.Phil 1st year (2021-23)

2. MOOD
EMOTIONS
FEELINGS

3. FEELINGS : are experienced consciously and
brought out by both emotional experience and
physical sensations
EMOTIONS : internal subjective experience,
facial expressions, physiological reactions
generally directed towards a object

4. MOOD
•“Mood is a pervasive and
sustained emotion that influences
a person’s behaviour and colours
his/her perception of the world”

5. “a disposition to respond emotionally in a particular way
that may last for hours, days or even weeks,perhaps at a
low level and without the person knowing what
prompted the state.Moods differ from emotions in lacking
an object ;for eg. The emotion of anger can be aroused by
an insult,but an angry mood may arise when one does not
know what one is angry about or what elicited the anger.”
- --
-APA dictionary of psychology

6. AFFECT
• Broad term used to cover mood,
feeling,attitude,prefernce and refers to expressions of
emotions as judged by the external manifestations that
are associated with specific mood
• Judged through
intensity,duration,quality,reactivity,communicability,ran
ge,appropriateness

7. HISTORY OF MOOD DISORDERS
• Ancient texts - evil spirits or wrongdoing
against God
• Hippocrates (460–377 BC) :
Melancholia(literally meaning ‘black bile’),
emanated from dysfunction of the brain

8. • Humoral theory - Pythagoras and Empedocles;
four humours, blood, phlegm, yellow and black
bile
• Christian Church - accidie [or acedia], one of
the seven deadly sins, which shared many of
the features of Melancholia, but with an
emphasis on sloth and apathy, and regarded as
induced by demons.

9. • 16-17 century : focus shifted to clinical
observations. Timothie Bright described
melancholia with and without cause. André du
Laurens (1560–1609) focussed on melancholic
delusions
• Most influential contribution came from
Robert Burton (1577–1640). Through The
Anatomy of Melancholy (1621)

10. • 18th century: introduction of
haemodynamic theories of the
pathogenesis of depressive states. Pitcairn
(1652– 1713), Boerhaave (1668–1738),
and Richard Mead (1673–1754)

11. • 19th century : ‘emotional insanities’, e.g.
tristimania (Benjamin Rush, 1745–1815),
lypemania (Esquirol, 1772–1840), and affective or
pathetic insanity (Henry Maudsley, 1835–1918).
• promotion of a variety of descriptive categories,
e.g. melancholy with and without delusion, with
and without stupor, active–passive, and simple or
complicated.

12. • 20th century : Emil kraeplin differentiated dementia precox
from mood disorders .
• Sigmund Freud (1856–1939) and Adolf Meyer (1866–1950);
For Freud, depression was the product of past, often remote
events as they affected the current life of the sufferer and
interpreted as a turning inward of aggression towards a lost
loved object.
• Meyer’s psychobiological school emphasized the uniqueness
of individual patients and conceived mental disorder as a
reaction to current stresses and past maladjustment.

13. •Hippocrates included the condition of
‘Mania’ in his triad of mental disorders,
alongside ‘Melancholia’ (see above) and
‘Phrenitis’, an acute mental disorder
accompanied by fever.

14. • Robert Burton in his Anatomy of Melancholy,
unitary disorder hypothesis, as he wrote: ‘They
[Mania and Melancholy] differ only in the more or
less quantity alone, the one being a degree to the
other and both proceeding from one cause.’
• Later in the 17th century, Thomas Willis
commented that ‘chronic melancholy not
infrequently degenerates into mania’

15. • Early 19th-century psychiatrists, whilst accepting that
melancholy and mania were related, differed on whether they
were separate disorders (Heinroth, Esquirol) or mania was a
more acute grade of melancholia (Pinel, Haslam).
• The first seeds of the modern concept of bipolar disorder
appeared in the mid-19th century with the separate
descriptions by two French psychiatrists, Pierre Falret (1794–
1870) and Jules Baillarger (1809–1890), of a distinctive
condition characterized by both melancholic and manic
phases, usually with normal intervening periods

16. • Emil Kraepelin dominated the turn of the
century by unifying all types of affective
disorder in ‘manic–depressive insanity’,
• Wernicke, who recognized five different types
of melancholia, and Kleist, who introduced the
terms ‘unipolar’ and ‘bipolar’ and regarded
mania on its own as distinct from manic–
depressive disorder

17. Depression
Bipolar
Mania
Dysthymia
Hypomania
Cyclothymia

18. PREVALANCE
One –year
prevalence(%)
Female : Male Typical age at
onset(years)
Major Depressive
Disorder
8.0 2:1 24-29
Persistent
depressive
disorder
1.5-5.0 Between
3:2 and 2:1
10-25
Bipolar I
1.6 1:1 15-44
Bipolar II
1.0 1:1 15-44
Cyclothymic
0.4 1:1 15-25

19. Statistics in India
• In India,the prevalence of affective disorder ranges
from 0.51 per 1000 population to 20.78 per 1000
population
• Depressive disorders contributed the most to the total
mental disorders DALYs,4.57 crore(33.8%,29.5-38.5)
The burden of mental disorders across the states of
India :The Global Burden of Disease Study 1990-
2017

21. Groundbreaking New Treatment For Bipolar Disorder (jan 3,2019)…photo courtsey : national psychiatric
association

22. When to say a MOOD DISORDER?
a)Is the person suffering ?
b)Is the expression of mood
inappropriate in the setting?

23. DEPRESSION
SIGNS
Emotion
al
Physical
Cognitiv
e
Behaviour
al

25. EMOTIONAL
• Most people who are
depressed feel sad and
dejected
• Describe themselves as
“miserable”,”empty”,’humiliat
ed”
• Anhedonia
• Anxiety,anger,guilt feelings
• Irritability,mood swings

26. Anhedonia(Ribot,1896)
• Described with unclear boundaries cutting
across tripartite model of
mind(affect,volition,cognition)
• Earlier views - many depressed patients only
reported loss of capacity to experience joy
and pleasure in everything.

27. Feeling of a loss of feeling
• deficiency that is all-pervasive,affecting all
emotions including sadness,joy,anger and so on
• Person resents or does not understand,it suffers
greatly and often feels guilty about the feeling
• A depressed young woman said-”I have no feelings
for my children. That is wicked .They are beautiful
children”

28. Melancholia
• Wiiliam Styron(1990) ,term depression was weak word for the
experience and ‘melancholic’
• Clinical features of Melancholia: • ‘aversion to food, despondency,
sleeplessness, irritability, and restlessness’,
• Hippocrates ‘Patients are dull or stern, dejected or unreasonably
torpid, without any manifest cause. They become peevish, dispirited,
sleepless; unreasonable fears also seize them. If the illness becomes
more urgent, hatred, avoidance of the haunts of men, vain
lamentations are seen. They complain of life and desire to die’,
Aretaeus of Cappadocia (81–138 AD).

29. Alexithymia(Sifneos,1972)
• Describes a specific disturbances in psychic functioning
characterized by difficulties in the capacity to verbalize affect and
elaborate fantasies.
• great difficulty in recognizing and describing their own feelings and
in discriminating between emotional states and bodily sensations.
• They show a stiff ,robot-like existence. There may be stiffness of
posture and lack of facial expressions
• Has been found in psychosomatic disorders,substance abuse
disorder, masked depression

30. Shame and guilt
• Both are regarded as self conscious and moral emotions. They
flow from human action, conduct where they sometimes be
regretted and deplored
• In SHAME ,focus of evaluation on self, arising from public
exposure and disapproval of shortcomings
• In GUILT, the self is not the central object of negative
evaluation,but rather the thing done and is seen as a private
experience deriving from self generated determination of
wrongdoing with the consequent guilt feelings.

31. • Kim et al(2011) showed that Shame and guilt
were equally present in depression but only
when specific types of guilt were considered
separetly
• Contextual-maladaptive guilt that involves
exaggeration of responsibility for
uncontrollable events
• In severe depression,delusional guilt is often
seen

32. BEHAVIOURAL
• Reduced activity in previous leisures
• Spend more time alone and may
spend more time in bed for long
periods
• Psychomotor retardation or agitation
• Low speech output
• Changes in appearance
• Crying spells
• Neglect of responsibilities
• Possibility of substance
abuse(especially alcohol)

33. Avolition
• Lack of motivation that makes it hard to
get anything done.One can’t start or finish
even simple,everyday tasks.
• Often sign of schizophrenia,can be seen in
severe depression also,side effect of
medicines

34. Blunting and Flattening of Affect
• Both terms are used interchangeably to refer to unchanging
facial expression,decreased spontaneous movements,poverty
of expressive gestures,poor eye contact,affective
unresponsivity and lack of vocal inflection
BLUNTING implies a lack of emotional sensitivity
FLATTENING is a limitation of the usual range of emotion expressed usually
by facial but also bodily gestures

35. PHYSICAL
• Physical ailments as
headaches,indigestion,constip
ation,dizzy spells,general pain
• Disturbed
sleep(insomnia/hypersomnia)
• Low energy and lethargy
• Disturbed appetite
• Weight changes(loss/gain)

36. Bodily feelings associated with
emotion
• In a number of cultures,depression is considered to have an
anatomic location to such extent that mood state and body
becomes synonymous.
• Melancholia literally means ‘black bile’
• In Urdu the word jee(self) describes the hypochondrium
anatomically and comes to mean depression(i.e. depression is
a central assault on the well being of the self)

37. • Physical illness frequently precipitated a loss of
accustomed sense of well being,subjectively
experienced as a generalized lowering of vitality
• Depressed patients frequently complain of
headache.On enquiry,they may say.”it’s not exactly
a pain,but more of unbearable feeling of pressure
like a rock on the head”
• Abdominal pain ,”it feels like a weight bearing
down on my chest,stopping me from breathing”

38. COGNITIVE
• Poor attention and concentration
span
• Thinking slowed down
• Impairments in memory(forgetting
everyday things)
• Indecisiveness,confusion
• Pessimistic views of future
• Feelings of
hopelessness,worthlessness,helplessn
ess
• Thoughts of death and suicide

39. Inhibition or slowing of thinking
• The train of thoughts is slowed down and no.of
ideas and mental images is itself decreased.
• This is experienced as difficulty in making
decisions,lack of concentration ,loss of
clarity,diminution in active attention,complain of
loss of memory
• The apparent cognitive defects may lead to
mistaken diagnosis of dementia(if patient is old)

40. Cognitive Triad

42. DSM-5(2013) ICD-10(2013)
CODE 296(Major Depressive
Disorder)
F 32(depressive episode)
DURATION 2 weeks 2 weeks
PRIMARY SYMPTOMS ATLEAST ONE OF THEM BE
PRESENT
•Depressed mood
•Loss of interest or pleasure
•Depressed mood
•Loss of interest or pleasure
•Reduced energy leading to
increased fatiguability and
diminished activity
SECONDARY SYMPTOMS FIVE(OR MORE ) BE PRESENT
•Significant weight loss when
not dieting or weight gaining(a
change of more than 5% of
body weight)
•Insomnia or hypersomnia
•Psychomotor agitation or
retardation
•Reduced concentration and
attention
•Reduced self esteem and
confidence
•Ideas of guilt and
unworthiness
•Pessimistic views of future

43. SECONDARY SYMPTOMS •Fatigue or loss of energy
•Feelings of worthlessness or
excessive or inappropriate
guilt ( not merely self reproach
or guilt of being sick)
•Diminished ability to think or
concentrate or indecisiveness
•Recurrent thoughts of
death(not just fear of
dying),recurrent suicidal
ideation without a specific
plan ,or a suicide attempt or a
specific plan for commiting
suicide
•Ideas or acts of self harm or
suicide
•Disturbed sleep
•Diminished appetite

44. DSM-5 criteria(B-E)
B:The symptoms cause clinically significant distress or impairment in
social,occupational or important areas of functioning
C : The episode is not attributable to the physiological effects of a
substance or to another medical condition
D: The occurrence of the major depressive episode is not better explained
by schizoaffective disorder ,schizophrenia ,schziophreniform
disorder,delusional disorder or other specified and unspecified
schiphrenia spectrum and other psychotic disorder
E: There has never been a manic or a hypomanic episode

45. DEPRESSION
Severity(ICD 10)
Mild
• 2 primary symptoms
• 2 secondary symptoms
Moderate
• 2 primary symptoms
• 3 secondary symptoms
Severe
• All primary symptoms
• 4 secondary symptoms
Single Depressive episode
ICD : F 32.0-32.9
DSM : 296.21-296.20
Recurrent depressive
episode(minimum 2 months gap )
ICD : F33.0-33.9
DSM : 296.31-296.30
•With somatic syndrome
•Without somatic syndrome
•With psychotic symptoms
•Without psychotic sypmtoms

46. Psychotic symptoms in Depression
a)Delusions
• Reference
• Guilt
• Nihilistic(Cotard Syndrome)
• Poverty
b)Hallucinations

47. DEPRESSION(DSM 5)

48. • The disorder may be additionally categorized as
seasonal if it changes with seasons(eg.if depression
recurs each winter)
• Catatonic,if marked my either their immobility or
excessive activity
• Peripartum ,if it occurs during pregnancy
,Postpartum if it occurs within 4 weeks of giving
birth

49. Disruptive Mood Dysregulation Disorder(296.99)
1. For at least a year,individual repeatedly displays severe
outbursts of temper that are extremely out of proportion to
triggering situations and different from ones dislayed by most
other people of his/her age.
2. Outbursts occur at least 3 times per week and in at least 2
settings
3. Repeatedly displays anger or irritable mood between outburts
4. Receives initial diagnosis between 6-18years of age.

50. Premenstrual dysphoric Disorder(625.4)
• In majority of menstrual cycles,At least 5 symptoms must be present
in final week before onset of menses,start to improve within few
days,and become minimal or absent in week postmenses
• SYMPTOMS :depressed or hopeless feeling;tense or anxious
feelings;marked mood changes;frequent irritability or anger and
increased interpersonal conflicts;decreased interest in usual
activities;poor concentration;lack of energy;changes in
appetite;insomnia or sleepiness;a sense of being overwhelmed or
control;physical symptoms such as swollen breasts,headaches,a
bloated sensation,weight gain

51. Persistent Depressive Disorder(DYSTHYMIA)
1.Person experiences symptoms of mild or
moderate depression for at least 2 years
2.During the 2-year period ,symptoms not absent
for more than 2 months at a time
3.No history of mania or hypomania
4.Significant distress or impairment

52. 1. General appearance and Behavior : generally kempt,eye contact
not met
2. Psychomotor Activity :retarded/agitated,crying spells
3. Speech:soft tone, increased reaction time,low productivity
4. Cognitive Functions : memory impairments mat be present
5. Mood and Affect : Dysphoric,depressed,distressed,constricted
,flat/blunt,restrcited range
6. Thought : Depressive cognitions
7. Perceptual Disorders : hallucinations
Mental Status Examination

53. SIGNS
Emotiona
l
Physical
Cognitive
Behaviour
al
MANIA

54. EMOTIONAL
• Person has active,powerful
emotions in search of an outlet
• Mood of euphoric joy and well
being is out of all proportions to
actual happening in person’s life
• Although some might become
very irritable and angry especially
when others get in the way of
their exaggerated ambitions

55. Elevated mood
• The positive feeling of joy and pleasure can be
intensified.
• “When you’re high it’s tremendous.The ideas and
feelings are fast ,shyness goes,the power to
captivate others a felt certainty.Inerests found in
unkniwn people.Sensuality is pervasive and desire
to seduce is irresisitible….”

56. Irritable mood
• “…..but somewhere this changes…everything
perviously moving with the grain is now against-
your are irritable,angry,frightened,uncontrollable
“
• It is clear that positive,joyful aspect of elevated mood
can quickly turn into dysphoric sensation that is
uncomfortable and unwelcome,yet that is not a variant
of depression

57. Euphoria
• Is the state of excessive unreasonable
cheerfulness,it may be manifested as extreme
cheerfulness,or it may seem inappropriate
and bizzare(in situation where its opposite
mood is expected)

58. Ecstasy
• Heightened states of happiness ,where the
patients describe being in tranquility and
everything around them is slow and smooth
• Characteristic of ecstasy is that it is usually
self-referent (eg : the flowers of spring ‘open
for me’ ‘at one with universe’)

59. BEHAVIOURAL
• Very active,move quickly as if there was
not enough time to do everything
• Expressions either too joking and clever
or complains and verbal outburts
• Hypersexuality
• Reckless money spending
• Flamboyance
• Enthusiastically seek out new,old friends
and interests
• Have little awareness that their social
style is excessive
• Talk too rapidly and loudly

60. PHYSICAL/MOTIVATIO
NAL
• Don’t feel the need for sleep
• Excessive energy that they can’t sit
still
• Enthusiastically seek out new,old
friends and interests
• Have little awareness that their social
style is excessive
• Wander aimlessly
• Involving in risky behaviours

61. COGNITIVE
• Flight of ideas
• Poor judgement and planning
• Unrealistic optimism
• Inflated self esteem reaching
to levels of grandiosity
• In severe cases ,start losing
touch with reality
• Delusions,hallucinations

62. Over valued ideas
• This is a thought
that,because of the
associated feeling
tone,takes precedence
over all other ideas and
maintains this
predecedence for a long
time but they tend to
have some degree of
basis in reality
Delusions
• False,unshakeable belief that
is out of keeping with social
and cultural background
• Delusions of :
1. Love(fantasy lover syndrome
and erotomania)
2. Grandiosity
The hallucinations are
generally in context of the
delusions, supporting the
patient’s beliefs.

63. Flight of ideas
• In this,thoughts follow each other rapidly,there is
no general direction of thinking and the
connection between successive thoughts appear
to be due to chance factors,which however,can ne
easily understood.
• The patient’s speech is easily diverted to external
stimuli and by internal superficial associations.

64. COMPARISON OF CRITERIA
ICD-10 DSM-5(under Bipolar and related disorders)-
Bipolar I
CODE F 30 296.41-296.43
DURATION 1 week 1 week
PRIMARY SYMPTOMS •Elevated mood
•Increase in quantity and speed of
physical and mental activity
•Elevated,expansive
,irritable mood
•Abnormally and persistently goal directed
activity or energy
SECONDARY SYMPTOMS Without Psychotic Symptoms
•Mood may vary from carefree
jovial to almost uncontrollable
excitement
•Pressure of speech
•Decreased need for sleep
3 or more symptoms need to be present
•Inflated self esteem or grandiosity
•Decreased need for sleep
•More talkative than usual or pressure to
keep talking

65. •normal social inhibitons are lost
•Marked distractibilty
•Self esteem inflated
•Grandiose or over optimistic ideas are
freely expressed
•Perceptual disorders may occur
•Preoccupation with fine details
•Subjective hyperacusis
•Reckless money spending
•Become aggressive
With psychotic Sypmtoms
•Inflated self esteem and grandiose ideas
may develop into delusions
•Irritability and suspiciousness into
delusions of persecution
•Grandiose or religious delusions of
identity
•Flight of ideas or subjective
experience that thoughts are racing
•Distractibilty
•Increase in goal directed activity or
psychomotor agitation(puroseless
non goal directed activity)
•Excessive involvement in activities
that have a high potentia for painful
consequences

66. •flight of ideas and
pressure of speech may
result in individual
becoming
incomprehensible
•Severe and sustained
physical activity may result
in violence
•Neglect f or personal
hygiene
•Hallucinations and
delusions can be present
The symptoms are severe enough to disrupt ordinary work
and social activities more or less completely

67. HYPOMANIA (F30.1)
DURATION
• Atleast several days on end
ICD 10
• Atleast consecutive 4 days
DSM-5
KEYPOINT : All the symptoms similar as mania ,but
not to the extent that they lead to severe disruption
of work or result in social rejection.

68. Mental Status Examination
1. General appearance and Behavior
2. Psychomotor Activity : increased
3. Speech: loud tone, reduced reaction time,increased productivity
4. Cognitive Functions
5. Mood and Affect :
Elevated,exalted,euphoric,ecstasy,irritable,labile,maybe inappropriate
sometimes
6. Thought : flight of
ideas,circumstantiality,tangeniality,volubility,prolixity,delusions
7. Perceptual Disorders : hallucinations

70. BIPOLAR(F31.0-31.9)
I(296.40-
296.46)
Depression
+ mania
II(296.89)
Depression+
hypomania
Euthymic
Dysthymia

71. CYCLOTHYMIA
ICD 10 DSM 5
CODE F34.0(Persistent mood [affective]
disorders)
301.13(Bipolar and Related
disorders)
DURATION Last for years For at least 2 years(at least 1 year in
children and adolescents)
SYMPTOMS •Persistent instability of
mood,involving numerous periods
of mild elation and mild depression
•Instability may pursue chronic
course ,although at times mood
maybe normal and stable for
months
•Mood swings are usually perceived
as being unrelated to life events
•There have been numerous periods
with hypomanic symptoms that
don’t meet criteria for a hypomanic
episode and numerous periods with
depressive symptoms that don’t
meet criteria for a major depressive
episode
•During 2-yr period hypomanic and
depressive periods have been
present for at least half the time
and person has not been without
symptoms for more than 2 months