Mood disorders


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Mood disorders

  2. 2. EMOTIONS AFFECT: MOOD:Short-lived, emotional Sustained and pervasiveResponse to an event
  3. 3.  Healthy persons experience a wide range of moods and have a large repertoire of emotional expressions, feel in control Mood disorders are a group of clinical conditions which are characterized a by sense of loss of control over one’s mood and subjective sense of distress, impaired interpersonal, social and occupational functioning
  4. 4. History Hippocrates (400 B.C.) used the terms mania and melancholia to describe mental disturbances Roman physician (30 A.D.) described melancholia as depression caused by black bile
  5. 5.  In 1854, Jules Farlet described a condition called folie circulaire: alternating moods of depression and mania In 1899, Emil Kraepelin described manic- depressive psychosis using most of the criteria that psychiatrists use now
  6. 6. CLASSIFICATION Manic Episode Depressive Episode Bipolar Affective Disorder Recurrent Depressive Disorder Persistent Mood Disorder (cyclothymia and dysthymia)
  7. 7. Mania: Clinical Features Core features  Elevated/irritable mood  Increased speech  Decreased need for sleep  Increased psychomotor activity Psychotic features  Delusions  Hallucinations Others 7
  8. 8. 1. Elevated/ irritable mood: o Euphoria/ Grade 1: mild elevation of mood, increased sense of psychological well being and happiness, not in keeping with ongoing events o Elation/ Grade 2: moderate elevation of mood, feeling of confidence and enjoyment, along with increased psychomotor activity o Exaltation/ Grade 3: severe elevation of mood, intense elation with delusions of grandiosity o Ecstasy/ Grade 4: very severe elevation of mood, intense sense of rapture or blissfulness 8
  9. 9. 2. Increased speech o Volubility o Acceleration o Pressured speech- difficult to interrupt o Flight of ideas- shift from topic to topic with cues o Prolixity- ordered flight of ideas3. Increased psychomotor activity o Over activity/ restlessness o Excitement o Stupor 9
  10. 10. 4. Psychotic symptoms Delusions: grandiose, love, persecutory Hallucinations
  11. 11. 5. Other symptoms o Over religiosity o Over spending/ expansive ideas o Over familiarity/ disinhibition o Appearance o Appetite may be increased, but decreased food intake due to over-activity o Decreased need for sleep
  12. 12. Psychiatric Interview =zA-fqvC02oM&feature=relmfu
  13. 13. DEPRESSIVE EPISODE: ClinicalFeatures1. Depressed Mood: Pervasive and persistent sadness Quantitatively and qualitatively different from sadness encountered in normal depression or grief Varies little from day to day and is often unresponsive to environmental stimuli
  14. 14. 2. Anhedonia: Loss of interest or pleasure in almost all activities/ earlier pleasurable activities Results in social withdrawal Decreased ability to function in occupational and interpersonal areas
  15. 15. 3. Anergia: Easy fatigability Increased effort to perform simple tasks
  16. 16. 4. Depressive ideation: Hopelessness Helplessness Worthlessness Feelings of guilt Death wishes Suicidal ideas
  17. 17. 5. Psychomotor Activity: Younger patients (less than 40): slowed thinking and activity, decreased energy, monotonous voice Older patients: agitation, marked anxiety, restlessness Severe depression: stupor
  18. 18. 6. Biological functions/ somatic syndrome: Insomnia Loss of appetite and weight Loss of sexual drive Early morning awakening (atleast 2 hrs) Diurnal variation
  19. 19. 7. Psychotic Symptoms: Delusions of guilt, nihilism, poverty Hallucinations
  20. 20. Other symptoms Difficulty in concentration Forgetfulness Low self-esteem Decreased self-confidence
  21. 21. Psychiatric Interview =4YhpWZCdiZc
  22. 22. Bipolar affective disorder Characterized by repeated episodes of disturbed mood and activity levels Disturbance consisting of elevation of mood, increased energy and activity on some occasion and on others of low mood, decreased energy and activity Recovery is usually complete in between the episodes 22
  23. 23. Recurrent Depressive Disorder Recurrent (at least 2 depressive episodes) of unipolar depression First episode occurs later than in bipolar, usually in the 5th decade Episodes last between 3 to 12 months Recovery is usually complete Often precipitated by stressful life events
  24. 24. Persistent Mood Disorders Persistent mood symptoms lasting for more than 2 years Not severe enough to be labeled as even hypomanic or mild depressive Persistent mild depression: dysthymia Persistent instability of mood between depression and mania: cyclotymia
  25. 25. Next Class Course and Prognosis Epidemiology Treatment Differential Diagnosis Co-morbidities Other syndromes of depression and mania
  26. 26. Psychiatric Interviews =4YhpWZCdiZc =zA-fqvC02oM&feature=relmfu
  27. 27. Course and Prognosis Average manic episode lasts for 3-4 months Average depressive episode lasts for 4-6 months Unipolar depression is usually longer than bipolar depression As age advances, intervals between 2 episodes shorten; duration and frequency increases
  28. 28. EpidemiologyPrevalenceAnnual incidence is <1%, milder forms oftenmissedSex ratioEqual prevalence among men and womenManic episodes more common in men anddepressive episodes more common in women 28
  29. 29. Age of onsetOnsetearlier than depressive episodeRanges from 5-50yrs; mean age 30yrsMarital statusMore common in divorced and single personsSocioeconomic statusHigher than average incidence among uppersocioeconomic status 29
  30. 30. Classification Bipolar type 1- having clinical course of one or more manic episodes and major depressive episodes Bipolar type 2 – characterized by episodes of major depression and hypomania 30
  31. 31. Diagnosis- ICD 10 criteria Hypomania- lesser degree of mania o Persistent mild elevation of mood- euphoria o Marked feelings of well being and efficiency o Increased energy and activity o Decreased need for sleep o Increased sociability and talkativeness o Not leading to severe disruption of work or social rejection o Present for several days on end (4 days) 31
  32. 32.  Mania without psychotic symptoms o Last for at least 1wk o Severe enough to disrupt ordinary work and social activities o Elated mood o Increased energy with over activity o Pressured speech o Decreased need for sleep o Marked distractibility o Disinhibited, overspending o Expansive ideas 32
  33. 33.  Mania with psychotic symptoms o More severe form o Delusions- grandiose and/or persecutory o Perceptual abnormalities o Severe and sustained physical activity, excitement o Flight of ideas, incoherence o Impaired personal care 33
  34. 34. EtiologyBiological theories2.Genetic factors3.Neurotransmitter theories- inconsistent o Dopamine- raised in mania and vice versa4.Neuroendocrine theories o CSF somatostatin- raised in mania and vice versa5.Neuroimaging and anatomy o Regions involved in regulation of normal emotions- PFC, antr cingulate, hippocampus, amygdala 34
  35. 35. Contd-Psychosocial theories2.Life events and stress o Play a formative role in depression; precipitating in mania o More often precede first rather than the subsequent episodes 35
  36. 36. Course Most often first episode is depression Average manic episode lasts 3-4mnths and depressive episodes 4-6mnths Long term follow up- 15% are well, 45% are well with multiple relapses, 30% in partial remission, 10% are chronically ill 36
  37. 37. Treatment Pharmacological- Acute- Mood stabilizers Antipsychotics Benzodiazapines Antidepressants ECTs Prophylaxis- Mood stabilizers Non pharmacological- Psycho education CBT Interpersonal 37
  38. 38. Contd-Mood stabilizersLithium- exact mechanism of actionunknown Indications- acute mania prophylaxis of unipolarand bipolar disorder adjuvant toantidepressant impulsive/ aggressivebehavior 38
  39. 39. Contd- Precautions- RFT, TFT, ECG Adverse effects- CNS- tremors,seizures, cognitive impairment,delerium Renal- DI, polyurea, dypsia CVS- hypokalemia- T wave Abnormal thyroid function GI- nausea, diarrhoea Skin- acne, psoriasis 39
  40. 40. Contd- Sodium valproate- acute mania, prophylaxis 750-2500mg/day rapid onset of response Carbamazepine Oxcarbazepine Lamotrigine- depression, prophylaxis; skin Topiramate 40
  41. 41. 41
  42. 42. Summary Clinical features- 4 core features psychotic features others Management- pharmacological- acute prophylaxis non-pharmacological 42
  43. 43. Poor prognostic factors Young onset Longer duration of episodes Presence of psychotic features Inter episode depressive features Premorbid poor occupational status Comorbid medical and psychiatric problems 43
  44. 44. EtiologyBiological theories2.Genetic factors o 3 fold increase in biological relative o Increased concordance rate for monozygotic twins o Chromosome 18, 21, 224.Neurotransmitter theories- inconsistent o Serotonin and norepinephrine- depression o Dopamine- reduced in depression and increased in mania 44
  45. 45. Contd-1. Neuroendocrine theories o Elevated HPA activity, hypothyroidism- depression o CSF somatostatin- raised in mania and vice versa3. Neuroimaging and anatomy o Regions involved in regulation of normal emotions- PFC, antr cingulate, hippocampus, amygdala o Ventricular enlargement 45
  46. 46. Contd-Psychosocial theories•Psychoanalytic theory- mania as defenseagainst underlying depression•Life events and stress o Play a formative role in depression; precipitating in mania o More often precede first rather than the subsequent episodes6.Cognitive theory- depression 46
  47. 47. Course Most often first episode is depression 10-20% experience only manic episodes Manic episodes typically have rapid onset Average manic episode lasts 3-4mnths and depressive episodes 4-6mnths Long term follow up- 15% are well, 45% are well with multiple relapses, 30% in partial remission, 10% are chronically ill 47