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Androu Waheeb
To be Discussed Affect Abnormalities    Episodes    Disorders Episodes secondary to Medical Illness Substance-Induce...
Affect Affect = mood = internal emotional state Can be triggered by internal and external stimuli Variation: range and ...
Abnormalities  Mood Episodes      Mood Disorders   (distinct time)   (pattern of episodes) Major Depressive    Major Depre...
Episodes 1             Mood Episodes              (distinct time)         Major Depressive                 Manic          ...
Episodes 2• 2+ weeks             • Sleep                • 1+ weeks                 • Distractability                      ...
Episodes 3• Same as mania except for   • 1+ weeks• 4+ days                    • Meets criteria for major• No psychotic sym...
Disorders 1          Mood Disorders          (pattern of episodes)         Major Depressive                Bipolar        ...
MDD - General DSM-IV TR   At least one MDE   No previous manic or hypomanic episodes Epidemiology    15% (USA)    12...
MDD - SubtypesMelancholic      Psychotic        Catatonic          Atypical  Anhedonia                        Immobility  ...
Seasonal Affective Disorder Type of Depression Diagnostic Triad: Irritability, Carbohydrate  Drawing, Hypersomnia Only ...
MDD - Etiology Biological               Genetic        Psychosocial 1. Serotonin decreased     50% mono-    1. Loss of par...
MDD - Course Natural history   Self-limiting (6-13/12)   Disorders increase in frequency temporally   15% commit suici...
MDD - Treatment                        • Suicide                        • Homicide    Hospitalization     • Cant care for ...
MDD – Anti-depressantPharmacotherapy                   Anti-depressants            all equally effective and need 4-8/52 t...
MDD – Anti-depressantPharmacotherapy 2 *Serotonin Syndrome    SSRI + MAOI    Diagnostic triad       Autonomic instabil...
MDD – Adjuvant Pharmacotherapy                                            Conversion of non-    Stimulants                ...
MDD - ECT Safe May be used alone 8 treatments over 2-3/52 Process  1. Atropine  2. General anesthesia  3. Muscle relax...
MDD - DDx                     Dysthymia               Adjustment Disorder            Bipolar II in depressed state        ...
CASE 1 65 y o Widow Not taking care of self Put in geriatric home Wakes up early Does no particular activity Stopped...
Disorders 2          Mood Disorders          (pattern of episodes)         Major Depressive                Bipolar        ...
Dysthymic Disorder – DSM Law of 2’s    Depressed mood most of time most of days for 2+ years     without MDE    Never w...
Dysthymic Disorder – General Epidemiology    < 1%    F:M = 3:1    Onset before 25 Course (Rule of 20’s)    Chronic d...
Dysthymic Disorder – Therapy Psychotherapy    Cognitive Therapy    Insight-Oriented Therapy Concurrent Anti-depressant...
Case 2 28 yo Female Sad since adolescnce Does not remember last fun activity Denis suicidal thought Denies hopelessne...
Disorders 3          Mood Disorders          (pattern of episodes)         Major Depressive                Bipolar        ...
Bipolar Disorder       Bipolar I               Bipolar II• 1+ manic or mixed     • 1+ MDE  episode               • 1+ hypo...
Bipolar I - General Epidemiology    1%    Onset before 30 Course    Untreated episode lasts 3/12    Chronic with rel...
Bipolar II – General Epidemiology    0.5%    Women more common    Onset before 30 Course    Chronic and requires lon...
Bipolar I & II - Etiology  Biological    75% mono-    Psychosocial   Environmental                  zygotic               ...
Bipolar I & II - Therapy                           • Lithium (Mood stabilizer)                           • Carbamezipine o...
Bipolar I & II – Therapy 2 Lithium Side Effects (GGD.FAWLT.UC.SAM)   1.  GI Disturbances   2. Gotire or Hypothyroidism   ...
Bipolar I & II – Rapid Cycling 4+ episodes in 1 year Especially responsive to anti-convulsants    Carbamezipine    Val...
CASE 3 35 yo Male Brought by wife Takes out loans to start business 3 hours of sleep Compares himself to Bill Gates ...
Disorders 4          Mood Disorders          (pattern of episodes)         Major Depressive                Bipolar        ...
Cyclothymic Disorder – DSM DSM - IV – TR   Many alternating periods with hypomanic and    depressive symptoms for 2+ yea...
Cyclothymic Disorder – Therapy Course    Chronic    33%  BPD Anti-manic agents used for BPD
CASE 4 28 yo student Female Feels moody Admits episodes of extreme happiness in last 2 years    Every day for a period...
Other Causes of MDE                                              Substance – Induced2o General Medical        Condition   ...
Other Causes of Manic Episode                                         Substance – Induced2o General Medical        Conditi...
Other Disorders of Note Minor Depressive Disorder    Not meet criteria for MDD (symptoms)    Not meet criteria for DD (...
References1. Abdelwahid HA, Al-Shahrani SI. Screening of   depression among patients in Family Medicine in   Southeastern ...
Affective Disorders
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Affective Disorders

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Affective Disorders

  1. 1. Androu Waheeb
  2. 2. To be Discussed Affect Abnormalities  Episodes  Disorders Episodes secondary to Medical Illness Substance-Induced Episodes Other Disorders of Note
  3. 3. Affect Affect = mood = internal emotional state Can be triggered by internal and external stimuli Variation: range and control  Normal: wide range, can control  Abnormal: abnormal range, can’t control
  4. 4. Abnormalities Mood Episodes Mood Disorders (distinct time) (pattern of episodes) Major Depressive Major Depressive Manic Bipolar Mixed Dysthymic Hypomanic Cyclothymic
  5. 5. Episodes 1 Mood Episodes (distinct time) Major Depressive Manic Mixed Hypomanic
  6. 6. Episodes 2• 2+ weeks • Sleep • 1+ weeks • Distractability increase/decrease • Expansile/ irritable/ • Insomnia• Anhednoia and/or • Appetite/weight elevated mood • Greandiosity depressed mood change • 3+ of DIG FAST • Flight of ideas• 4+ of other SAME • Mood depressed symptoms (4+ if CIGS symptoms • Energy decreased • Activity irritable mood) increased• No medical or • Concentration • No medical or decreased • Speech substance abuse substance abuse cause pressured cause • Interest decreased (Anhedonia) • Significant social and • Thoughtless-• Significant social occupational ness • Guilt/ and occupational worthlessness impairment • 75% have impairment • Suicide thoughts • Psychiatric emergency psychotic symptoms Major Manic Depressive
  7. 7. Episodes 3• Same as mania except for • 1+ weeks• 4+ days • Meets criteria for major• No psychotic symptoms depressive AND manic• No significant episodes impairment of function• Not an emergencyHypomanic Mixed
  8. 8. Disorders 1 Mood Disorders (pattern of episodes) Major Depressive Bipolar Dysthymic Cyclothymic
  9. 9. MDD - General DSM-IV TR  At least one MDE  No previous manic or hypomanic episodes Epidemiology  15% (USA)  12% (SE KSA)1  M:F=1:2  Average onset 40 y
  10. 10. MDD - SubtypesMelancholic Psychotic Catatonic Atypical Anhedonia Immobility Hyperphagia Early morning Delusions Purposeless Hypersomnia awakening motor activity Psychomotor Negativism Reactive mood disturbances Guilt Bizarre posture Laeden paralysis Hallucinations Hypersensitive to Anorexia Echolalia rejection
  11. 11. Seasonal Affective Disorder Type of Depression Diagnostic Triad: Irritability, Carbohydrate Drawing, Hypersomnia Only present in winter Due to lack of sunlight Rx: Light therapy
  12. 12. MDD - Etiology Biological Genetic Psychosocial 1. Serotonin decreased 50% mono- 1. Loss of parent 2. Abnormal b- zygotic before 11 years adronergic receptor concordance regulation 2. Poor stability of 3. High cortisol (HPA family structure hyperactivity) 3. Poor social 4. Thyroid disorder functioning (TSH response to TRH blunted)
  13. 13. MDD - Course Natural history  Self-limiting (6-13/12)  Disorders increase in frequency temporally  15% commit suicide (USA)  50% receive treatment 75% treated successfully
  14. 14. MDD - Treatment • Suicide • Homicide Hospitalization • Cant care for self • Anti-depressants • Adjuvant medication Pharmacotherapy • CBT • Family Therapy Psychotherapy • Non-responding Electro-convulsive • Non-tolerating • Rapid recovery required Rx
  15. 15. MDD – Anti-depressantPharmacotherapy Anti-depressants all equally effective and need 4-8/52 to workSSRI TCA MAOI(safer. Better tolerated) (Lethal in Overdose) (Refractory Depression) • Sedation • Orthostatic• Headache hypotension • Weight gain• GI disturbance • Orthostatic • Serotonin syndrome* if hypotension + SSRI• Sexual • Hypertensive crisis if + • Anti-cholinergic effects dysfunction sympathetomimetics or • Aggravates long QT• Rebound anxiety tyramine-rich food syndrome
  16. 16. MDD – Anti-depressantPharmacotherapy 2 *Serotonin Syndrome  SSRI + MAOI  Diagnostic triad  Autonomic instability  Hyperthermia  Seizures  May result in coma or death
  17. 17. MDD – Adjuvant Pharmacotherapy Conversion of non- Stimulants Antipsychotics responders to (methylphenidate) responders• Indications • Psychotic MDD • Liothyronine • Terminally ill • Levothyroxine • Refractory • Lithium symptoms • L-tryptophan• Cause dependence
  18. 18. MDD - ECT Safe May be used alone 8 treatments over 2-3/52 Process 1. Atropine 2. General anesthesia 3. Muscle relaxants 4. Induce generalized seizure S/E: Temporary retrograde amnesia for 6/12
  19. 19. MDD - DDx Dysthymia Adjustment Disorder Bipolar II in depressed state Parkinson’s Disease Brain Tumor Cocaine Abuse B-Blocker Side Effect Hyperthyroidism Hypothyroidism Syphilis
  20. 20. CASE 1 65 y o Widow Not taking care of self Put in geriatric home Wakes up early Does no particular activity Stopped going to Bingo meetings Claims there is nothing for her life
  21. 21. Disorders 2 Mood Disorders (pattern of episodes) Major Depressive Bipolar Dysthymic Cyclothymic
  22. 22. Dysthymic Disorder – DSM Law of 2’s  Depressed mood most of time most of days for 2+ years without MDE  Never without symptoms > 2/12  2+ of CHASES symptoms 1. Concentration reduced 2. Hopelessness 3. Appetite reduced or overeating 4. Sleep increased or decreased 5. Energy reduced 6. Self-esteem reduced Never manic or hypomanic episode
  23. 23. Dysthymic Disorder – General Epidemiology  < 1%  F:M = 3:1  Onset before 25 Course (Rule of 20’s)  Chronic disorder (MDD is episodic)  Never get psychotic symptoms  20%  MDD  Double Depression: MDD+DD in between MDE’s  20%  BPD  20%  Lifelong symptoms
  24. 24. Dysthymic Disorder – Therapy Psychotherapy  Cognitive Therapy  Insight-Oriented Therapy Concurrent Anti-depressants  SSRI + MAOI + TCA
  25. 25. Case 2 28 yo Female Sad since adolescnce Does not remember last fun activity Denis suicidal thought Denies hopelessness Denies sleep impairment
  26. 26. Disorders 3 Mood Disorders (pattern of episodes) Major Depressive Bipolar Dysthymic Cyclothymic
  27. 27. Bipolar Disorder Bipolar I Bipolar II• 1+ manic or mixed • 1+ MDE episode • 1+ hypomanic episode• Interspersed with • Never a manic episode • MDE (most common) • Dysthymia • Hypomanic episode • Euthymia
  28. 28. Bipolar I - General Epidemiology  1%  Onset before 30 Course  Untreated episode lasts 3/12  Chronic with relapses  7% do not recur  Increased frequency of episodes with progression  50% of treated patients improve
  29. 29. Bipolar II – General Epidemiology  0.5%  Women more common  Onset before 30 Course  Chronic and requires long term treatment
  30. 30. Bipolar I & II - Etiology Biological 75% mono- Psychosocial Environmental zygotic concordance
  31. 31. Bipolar I & II - Therapy • Lithium (Mood stabilizer) • Carbamezipine or Valproic Acid* (Anticonvulsant used as mood stabilizer) Pharmacotherapy • Olanzapine (atypical antipsychotic) • Supportive Psychotherapy • Family Therapy Psychotherapy • Group Therapy • More treatments than MDD • Works well Electro-convulsive Rx
  32. 32. Bipolar I & II – Therapy 2 Lithium Side Effects (GGD.FAWLT.UC.SAM) 1. GI Disturbances 2. Gotire or Hypothyroidism 3. PolyDipsia 4. Fatigue 5. Arrhythmia 6. Weight Gain 7. Leukocytosis 8. Tremor 9. PolyUria 10. Coma 11. Seizures 12. Allopecia 13. Metallic Taste
  33. 33. Bipolar I & II – Rapid Cycling 4+ episodes in 1 year Especially responsive to anti-convulsants  Carbamezipine  Valproic acid
  34. 34. CASE 3 35 yo Male Brought by wife Takes out loans to start business 3 hours of sleep Compares himself to Bill Gates Previous suicide attempt Previously felt hopeless
  35. 35. Disorders 4 Mood Disorders (pattern of episodes) Major Depressive Bipolar Dysthymic Cyclothymic
  36. 36. Cyclothymic Disorder – DSM DSM - IV – TR  Many alternating periods with hypomanic and depressive symptoms for 2+ years  Never symptom free for > 2/12  Never MDE or Manic Episode Epidemiology  < 1%  Coexist with Borderline Personality Disorder  Onset 15-25
  37. 37. Cyclothymic Disorder – Therapy Course  Chronic  33%  BPD Anti-manic agents used for BPD
  38. 38. CASE 4 28 yo student Female Feels moody Admits episodes of extreme happiness in last 2 years  Every day for a period  Admits lapse of judgment  a/w increased energy Irrational depression of mood
  39. 39. Other Causes of MDE Substance – Induced2o General Medical Condition • CVD • Sedative-Hypnotics • Endocrinopathies • Psychostimulant • Parkinson’s Dx withdrawal • Mononucleosis • Anti-convulsants • Carcinoid Syndrome • Anti-psychotics • Lymphoma • Alcohol • Pancreatic CA • Anti-hypertensives • SLE • Barbituates • Corticosteroids • Diuretics
  40. 40. Other Causes of Manic Episode Substance – Induced2o General Medical Condition • Hyperthyroidism • Antidepressants • Temporal Lobe • Levodopa Seizure • Dopamine • MS Agonists • Neoplasms • Sympatomimetics • HIV • Bronchodilators • Corticosteroids
  41. 41. Other Disorders of Note Minor Depressive Disorder  Not meet criteria for MDD (symptoms)  Not meet criteria for DD (euthymic periods) Recurrent Brief Depressive Disorder Premenstrual Dysphoric Disorder Mood Disorder Not Otherwise Specified (NOS)
  42. 42. References1. Abdelwahid HA, Al-Shahrani SI. Screening of depression among patients in Family Medicine in Southeastern Saudi Arabia. Saudi medical journal. Sep;32(9):948-52.2. First Aid for the Psychiatry Clerkship

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