Mood disorders


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Mood disorders

  1. 1. Mood vs. Affect• Mood – pervasive and sustained feeling tone that is experienced internally and influences a person’s behavior and perception of the world• Affect – external expression of mood Healthy person experience a wide range of moods and have an equally large repertoire of affective expressions; they feel in control of their moods and affect
  2. 2. Mood Disorders• Definition: – a group of clinical conditions characterized by a loss of that sense of control and a subjective experience of great distress• Categories – Unipolar depression / Depressive Disorder – Bipolar disorder I & II – Hypomania – Cyclothymia – Dysthymia
  3. 3. EpidemiologyIncidence and prevalence – MDD is common with lifetime prevalence of 5 to 12% for men and 10 to 25% for women. – Bipolar I disorder is less common than MDD with a lifetime incidence of about 1%
  4. 4. Sex Age Socio-cultural• MD and manic • onset of bipolar • Depressive episode is > is usually at the disorder > common in age of 30 (also common in woman can occur in single and• bipolar I is equal children and divorced person. in both men and older adults) • No correlation women • MD occurs along with• depressive entire stage socioeconomic episodes is > spectrum status, races and common in men religious group
  5. 5. ETIOLOGY• Biological factors – Biogenic amine – Neuroendocrine regulation – Sleep – Kindling – Genetic factors• Psychosocial factors
  6. 6. Biologic • Heterogenous dysregulation of biogenic amine, based on findings of abnormal level of monoamine metabolites HVA, 5-HIAA and MHPG in blood, urine and CSF of patient • Serotonin depletion is associated with depressionBiogenic amine • Low levels of 5-HIAA are assoicated with violence and suicide • dopamine activity may be reduced in depression and increased in mania • Reflects disruption in biogenic amine input to the hypothalamusNeuroendocrine • Hyperactivity of the hypothalamic-pituatary-adrenal axis in depression leads to increased cortisol secretion regulation • In depression, there is decrease release of TSH, GH, FSH, LH and testosterone • Immune fx are decreased in both mania and depression
  7. 7. • In depression, abnormality include delayed sleep onset, shortened rapid eye movement (REM) latency, increased length Sleep of first REM episode and abnormal delta sleep • Multiple awakenings and decreased total sleep time are common in mania • Sleep deprivation has been found to have anti-depressant effect • Mood disorders may be a consequence of kindling in theKindling temporal lobes • Kindling is a process by which repeated subthreshold stimulation of a neuron generates an action potential • This stimulation leads to a seizure at an organ level • Both bipolar and depressive disorders run in families, but evidence of heritability is higher in bipolar disorderGenetic • Genetic association between the mood disorder, particularly bipolar I disorder, and genetic marker have been reported for chromosome 5, 11, and X
  8. 8. PsychosocialPsychoanalytic• Freud described internalized ambivalenbe toward a love object, which can produce a pathological form of mourning if object is loss or perceived loss• The mourning takes the form of severe depression with feelings of guilt, worthlessness and suicidal ideation• Symbolic or real loss of love object is perceived as rejection• Mania and elation are viewed as defense against underlying depressionPsychodynamic• In depression, introjection of ambivalently viewed loss objects leads to an inner sense of conflicts, guilt, rage, pain and loathing; a pathological mourning becomes depression as ambivalent feelings meant for introjected objects are directed at self• In mania, feelings of inadequacy and worthlessness are converted by means of denial, reaction formation and projection to grandiose delusions
  9. 9. Cognitive• Cognitive triad of Aaron Beck • Negative self view • Negative interpretation of experience • Negative view of futureLearned Helplessness• A theory that attributes depression to a person’s inability to control events• Theory is derived from observed behaviour of animals experimentally given unexpected random shocks which they cannot escapeStressful life events• Often precedes first episode of mood disorder• Such events may cause permanent neuronal changes that predispose a person to subsequent episode of a mood disorder• Losing a parent before age 11 is the life event most associated with later development of depression
  10. 10. MOOD EPISODE – distinct periods of time in which - Defined by their patterns of some abnormal mood is present. mood episodes - They include depression, mania, - Includes Major Depressive mixed-state, and hypomania Disorder (MDD), Bipolar I and II, dsythymic disorder, and cyclothymic disorder MOOD DISORDERS
  11. 11. (DSM-IV criteria)MOOD EPISODES
  12. 12. MAJOR DEPRESSIVE EPISODEA. ≥5 of the following sx , presented during the same 2-week period and represent a change from previous functioning; at least one of the sx is (1) depressed mood or (2) loss of interest or pleasure Depressed mood most of the Markedly diminished interest day, nearly everyday as or pleasure in all or almost all Significant weight loss when indicated by either subjective activities most of the not dieting or weight gain reports or observation made days, nearly everyday by others Insomnia or hypersomnia Psychomotor agitation or nearly everyday Fatigue or loss of energy retardation nearly everyday Recurrent thoughts of death, recurrent suicidal ideation Feelings of worthlessness or Diminished ability to think or without a specific plan, or a excessive or inappropriate guilt concentrate, or indecisiveness, suicide attempt or a specific nearly everday nearly everyday plan for commiting suicide
  13. 13. B. The symptoms does not meet criteria for a mixed episodeC. The symptoms cause clinically significant distress or impairment in social, occupational, or other important area of functioningD. The symptoms are not due to direct physiological effect of substance or a general medical conditionE. The symptoms are not better accounted for by bereavement, 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
  14. 14. Information from historyI. Depressed mood for a prolonged period of timeII. Anhedonia: inability to experience pleasureIII. Social withdrawalIV. Lack of motivation, little tolerance of frustrationV. Vegetative signs a. Loss of libido b. Weight loss & anorexia or c. Weight gain & hyperphagia d. Low energy level e. Abnormal menses f. Early morning awakening g. Diurnal variation: symptoms worse in the morning h. Constipation i. Dry mouth j. headache
  15. 15. Information from MSE• General appearance: psychomotor retardation or agitation, poor eye contact, tearful, downcast, inattentive to personal appearance• Affect: constricted or labile• Mood: depressed, irritable, frustrated, sad• Speech: little or no spontaneity; monosyllabic; long pauses; soft, low monotone• Thought content: distractible, difficulty concentration, complaints of poor memory, apparent diorientation abstract thought may be impaired• Insight and judgement: impaired because of cognitive distortions ofpersonal worthlessness
  16. 16. MANIA (MANIC EPISODE)Persistent elevated expansive mood Criteria A : -a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week
  17. 17. Criteria B Inflated self Decreased need esteem or Talkative for sleep grandiosity Excessiveinvolvement in Increase in goal- pleasurable Flight of ideas directed activity activity thathave a high risk of negative consequences Distractibility 3≤ persisted symptoms / 4≤ if the mood is only irritable
  18. 18. Criteria C :• -The symptoms do not meet criteria for mixed episodeCriteria D :• -The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in social activities or relationships with othersCriteria E :• -The symptoms are not due to direct physiologic effects of a substance, or general medical condition
  19. 19. Erratic and disinhibited behavior Information Overextended inVegetative signs obtained activities and from history responsibilities Low frustration tolerance with irritability, outbursts of anger
  20. 20. MENTAL STATUS EXAMINATIONGENERAL • -psychomotor agitation, colourful clothing, excessiveAPPEARANCE AND makeup, inattention to personal appearance, intrusive,BEHAVIOUR entertaining, threatening, hyperexcitedAFFECT • -labile, intense ( may have rapid depressive shifts)MOOD • -euphoric, irritable, demanding, flirtatious • -pressured, loud, dramatic, exaggerated; may becomeSPEECH : incoherent
  21. 21. • -flight of ideas, neologism, clangTHOUGHT PROCESS associations, circumstantiality, tangentiality • -highly elevated self esteem, grandiose,THOUGHT CONTENT delusions, less frequently hallucinations (mood congruent themes of self worth and power) • -highly distractible, difficulty concentrating, COGNITION memory intact if not too distracted, generally intact INSIGHT & • -extremely impaired, total denial of illness and JUDGEMENT inability to make any rational decisions.
  22. 22. Criteria A• A distinct period of persistently elevated, expansive or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.
  23. 23. Criteria B• 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 subjective experience that thoughts are racing• 5) distractibility• 6) increase in goal-directed activity or psychomotor agitation• 7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., foolish business investments)
  24. 24. Criteria C • The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.Criteria D • The disturbance in mood and the change in functioning are observable by others.Criteria E • The mood disturbance not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.Criteria 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 (e.g., hyperthyroidism)
  25. 25. MANIA HYPOMANIA• Last at least 7 days • Last at least 4 days• Causes severe impairment • No marked impairment in in social or occupational social or occupational functioning functioning• May necessitate • Does not require hospitalization to prevent hospitalisation harm to self or others • No psychotic features• May have psychotic features
  26. 26. MIXED EPISODE• Criteria are met for both manic episode and major depressive episode• These criteria must be present nearly everyday for at least 1 week• The symptoms of mania and depression occur simultaneously.• *example : tearfulness during a manic episode or racing thoughts during a depressive episode.• Mixed states are often the most problematic period of mood disorders, increase susceptibility to substance abuse, panic disorder, commission of violence, suicide attempts, and other complications.• A psychiatric emergency!!
  28. 28. Depressive disorders • Can occur alone or as part of bipolar disorder • Occurs alone = unipolar depression • Symptoms must be present for at least 2 weeks and represent a change from previous functioning • > common in women than man 2:1 • Precipitating event occurs in at least 25% patients Major • Diurnal variation, with symptoms worse early inDepressive the morning disorder • Psychomotor retardation or agitation is present • Associated with vegetative signs • Mood congruent delusions and hallucination may present • May occur single episode or recurrent
  29. 29. Major Depressive Disorder, single episode • Presence of a single Major Depressive EpisodeA • The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder,B or Psychotic Disorder Not Otherwise Specified • There has never been a Manic episode, a Mixed episode or a Hypomanic episodeC
  30. 30. Major Depressive Disorder, RecurrentPresence of 2 or more Major Depressive EpisodesThe Major Depressive Episode is not better accounted for by SchizoaffectiveDisorder and is not superimposed on Schizophrenia, SchizophreniformDisorder, Delusional Disorder, or Psychotic Disorder Not Otherwise SpecifiedThere has never been a Manic episode, a Mixed episode or a Hypomanicepisode
  31. 31. If the full criteria are CURRENTLY MET for a Major DepressiveEpisode, specify its current clinical status and/or features • Mild, Moderate, Severe without psychotic features/ severe with Psychotic features • Chronic • With catatonic features • With melancholic features • With atypical features • With postpartum onsetIf the full criteria are NOT CURRENTLY MET for a Major DepressiveEpisode, specify the current clinical status of the Major DepressiveDisorder or features of the most recent episode • In partial remission, In full remission • Chronic • With catatonic features • With melancholic features • With atypical features • With postpartum onset
  32. 32. Other features Melancholic Atypical Catatonic Psychotic• 40-60% of • Characterized by • Features includes • 10-25% of hospitalised patients hypersomnia, catalepsy, hospitalized with major hyperphagia, reactive purposeless motor depression depression moods, leaden activity, extreme • Characterized by the• Characterized by paralysis, and negativism or presence of delusions anhedonia, early hypersensitivity to mutism, bizarre and hallucinations morning awakenings, interpersonal postures, echolalia psychomotor rejection • Responsive to ECT disturbance, excessive guilt, and anorexia
  33. 33. Bereavement• Known as “simple grief”, is a rx to a major loss, usually of a person• Sx often last for 2 month and include crying spells, problems sleeping, and trouble concentrating at work• should not include gross disorganization and suicidality Normal Grief Depression • Illusions are common • Hallucination and delusion is • Suicidal thought are rare common • Sx lasts for <2m • Suicidal thought may be present • Mild cognitive disorder typically lasts • Sx usually persist >2m <1 year • Mild cognitive disorder usually lasts • Patient can be tx with mild for >1 y benzodiazepine for sleep • Patient can be tx w anti-depressant, mood stabilisers and ECT
  34. 34. Management of depressive disorders Make diagnosis and assess severity - Select anti-depressant treatment - Assess need for hospital treatmentor multidisciplinary team involvement - Coonsider precipitating/maintaining factorsExplain diagnosis, treatment plan, likely effects of treatment (benefit and harms) to patient and relative - Review after 7 days - Assess side effects , provide explanation and reassurance - Monitor every 7-14 days - Assess response to treatment by 6 weeks (earlier if condition worsen)
  35. 35. Cont.. Assess response to treatment by 6 weeks (earlier if condition worsen) If better, If not better, - Continue treatment - Review diagnosis- Review need to modify precipitating and - Review adherence maintaining factors - Review dosage When recovered If treatment adequate: - Continue anti-depressant for 6 - Consider another anti-depressant months or referral for specialist advice - Consider long term treatment for at least 2 years If treatment inadequate - increase and review once or twice weekly
  36. 36. TreatmentHospitalization Electroconvulsive Therapy (ECT)• Indicated if patient is at risk of • Indicated if patient is unresponsive suicide, homicide, or is unable to to pharmacotherapy, cannot care for self tolerate pharmacotherapy or rapid reduction of sx is required • Safe and may be used alone or in combination with pharmacotherapyPharmacotherapy• Anti-depressant medication • Selective serotonin reuptake inhibitors (SSRIs) – Venlafaxine, Duloxetine, Bupropion • Tricyclic antidepressant (TCA’s) - • Monoamine Oxidase Inhibitors Psychotherapy (MOIs) • Behavioral therapy, cognitive• Adjunct medication therapy, supportive therapy, • Stimulants (methylphenidate) – used psychoanalysis and family therapy in certain patient. • Anti-psychotic
  38. 38. • Depressive neurosis• Chronic, mild depression most of the time with no discrete episode• They rarely need hospitalization• MDD tends to be episodic, while dysthymic disorder is generally persistent• Epidemiology – – lifetime prevalence (6%) – 2-3x > common in women – Onset before age 25 in 50% of patients
  39. 39. • Insidious onset• Occurs most often in persons with a history of long term stress or sudden losses• Often coexist with other psychiatric disorder (substance abuse, personality disorder, OCD)• Sx tends to be worse later in the day
  40. 40. DSM-IV CriteriaA. 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. (In children and adolescent, mood can be irritable and duration must be at least 1 year)B. Presence, while depressed, of 2 (or more) of the following: 1. Poor appetite or overeating 2. Insomnia or hypersomnia 3. Low energy or fatigue 4. low self esteem 5. Poor concentration or difficulty making decisions 6. Feelings of hopelessness
  41. 41. C. During the 2-year period (1 year for children or adoloscents) of the disturbance, the person has never been without symptoms in Criteria A and B for more than 2 months at a timeD. No Major Depressive Episode has been present during the first 2 years of the disturbance (1 year for children and adolescents)E. There has never been a Manic episode, a Mixed episode or a Hypomanic episode and criteria have never been met for Cyclothymic disorder
  42. 42. D. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional DisorderE. The symptoms are not due to the direct physiological effects of a substanceor a general medical conditionF. The symptoms cause clinically significant distress or impairment in social, occupational, or other important functioning
  43. 43. • Course & prognosis – 20% will develop major depression – 20% will develop bipolar disorder – >25% will have lifelong symptoms• Treatment – Cognitive therapy and insight-oriented psychotherapy are most effective – Anti-depressants are useful when used concurrently with psychotherapy
  45. 45. Bipolar I DisorderA syndrome in which a complete set of mania symptoms occursduring the course of the disorderThe DSM-IV criteria for a manic episode requires the presence of adistinct period of abnormal mood lasting at least 1 weekManic episodes clearly precipitated by anti-depressant treatment(eg pharmacotherapy, ECT) does not indicate bipolar I disorderDivided into• Single manic episode• Recurrent
  46. 46. Bipolar II Disorder• The diagnostic criteria for bipolar II disorders is characterized by depressive episodes and hypomanic episodes during the course of the disorder, but the episodes of manic-like symptoms does not quite meet the diagnostic criteria for a full manic syndrome
  47. 47. OTHER TYPES OF BIPOLAR DISORDERS 1) RAPID-CYCLING BIPOLAR DISORDER : can occur at any is not in itself a diagnosis, time in the course 4 or more a course specifies for of bipolar disorderdepressive, manic bipolar disorder that and may come andor mixed episode describes the pattern and go at varying pointswithin 12months. frequency of episodes over a lifetime during a one year period. course of illness
  48. 48. 2) HYPOMANIA : -elevated mood associated with -unlike with fulldecreased need for mania, those with -less severe than sleep, extremely hypomanic mania, with no outgoing and symptoms are psychotic features competitive, and often fully have a great deal functioning of energy.
  49. 49. TREATMENT OF BIPOLAR DISORDERS PHARMACOTHERAPY :• Lithium (mood stabilizer) • -70% treated with lithium show partial reduction of mania • -mortality rate is 25% from acute overdose, due to low therapeutic index
  50. 50. ATYPICALANTICONVULSANTS ANTIPSYCHOTICS(carbamazepine, valproic (olanzapine,quetiapine,acid) ziprasidone)• -act as mood stabilizers • -effective as both• -especially useful for monotherapy and rapid cycling bipolar adjunct therapy for disorder and mixed acute mania episodes
  51. 51. ANTIDEPRESSANTS•-Are discouraged as monotherapy due to concerns of activating mania or hypomania•-The addition of antidepressants as adjunct therapy to mood stabilizers are shown not to be effective
  52. 52. TREATMENT OF ACUTE MANIC EPISODES-requires adjunctive use of potent sedative drugs-example : clonazepam, lorazepam, haloperidol,olanzapine and risperidone
  53. 53. • PSYCHOTHERAPY :-supportive psychotherapy, family therapy, grouptherapy (prolongs remission once the acute manicepisode has been controlled)• ELECTROCONVULSIVE THERAPY-works well in treatment of manic episodes-especially effective for refractory or lifethreatening acute mania or depression
  54. 54. CYCLOTHYMIC DISORDERLess severe disorderAlternating periods of HYPOMANIA and MODERATE DEPRESSIONChronic and non psychoticSymptoms must be present at least 2 yearsEqually common in males and femalesInsidious onset and occur in late adolescence or early adulthood.Substance abuse is commonRecurrent mood swing
  55. 55. DSM-IV-TR CYCLOTHYMIC DISORDER CRITERIA A : CRITERIA B : CRITERIA C:• -at least 2 • -during the • -no major years, presence above 2-year depressive of numerous period, the episode, manic periods with person has not episode, or hypomanic been without mixed episode symptoms and the symptoms has been depressive for more than 2 present during symptoms (in months at a the first 2 years children, durati time of disturbance on must be at least a year)
  56. 56. Criteria D : Criteria E : Criteria F :• -The symptoms in criterion A are not • -Symptoms • -The better accounted are not due symptoms for by to direct cause SCHIZOAFFECTIVE disorder, and are physiologic clinically not superimposed effects of a significant on SCHIZOPHRENIA, SCHIZOPHRENIFOR substance or distress or M, DELUSIONAL general impairment DISORDER, or medical in social, PSYCHOTIC DISORDER not condition. occupational otherwise specified and other areas.
  57. 57. TREATMENTAntimanic agents used to treat bipolar disorders• The use of antidepressants as monotherapy typically worsens cyclothymia and can induce mood switchingTherapy• Cognitive behavioural therapy (CBT)• Interpersonal psychotherapy (IT)• Group therapy
  59. 59. Myxedema madness Mad Hatter’s Syndrome• Hypothyroidism •Chronic mercury associated fatigability, intoxication produces depression and suicidal manic (sometimes impulses depressive) symptoms• May mimic schizophrenia with thought disorder, delusion, hallucination, paranoia and agitation• > Common in women
  60. 60. Neurologic and Medical Causes of Depressive and Manic SymptomsNeurologic Endocrine Infectious and Miscellaneous inflammatory medical•CVA •Adrenal (Cushing’s, •AIDS •Cancer (pancreatic,•Dementia Addison’s Dz) •Chronic fatigue n other GI)•Epilepsy •Hyperaldosteronis syndrome •Cardiopulmonary•Huntington’s dz m •Mononucleosis Dz•Hydrocephalus •Menses-related •Peumonia •Porphyria•Infections (HIV, •Parathyroid •Rheumatoid •Uremianeurosyphillis) disorder arthritis •Vit Deficiency•Migraine •Post-partum •Sjogren arteritis (B12, folate, niacin,•Multiple sclerosis •Thyroid disorder •SLE thiamine)•Narcolepsy •Temporal arthritis•Neoplasm •Tuberculosis•Parkinson Dz•Wilson’s DZ