This document provides an outline and overview of mood disorders including depression and bipolar disorder. It discusses the types of mood disorders, symptoms of major depressive disorder and bipolar disorder, risk factors and etiological factors. Treatment options and differences between DSM-5 and ICD-11 criteria for depression are also summarized. The document aims to increase understanding of common mood disorders and how they affect individuals.

1. Presented to/ Dr. Khaled Abd El- Moez

2. OUT LINES
• Introduction
• What is mood disorders
• Statistic on mood disorders
• Types of Mood Disorder
• Symptoms of Depressive
Disorder
• Differents between DSM 5
& ICD 11
• Etiological Factors of
Depressive Disorder
• Treatment of Depressive
Disorder
• Symptoms of Bipolar
Disorder
• Etiological Factors of Bipolar
Disorder
• Complications associated with
depression include
• Prevention steps
• Treatment of Bipolar
Disorder

3. Introduction
• Feeling elated one day and sad the next is common. Mood
fluctuations are a normal part of life. However, for some
people, these changes are severe and impair their ability to
live a normal life. These people likely live with a mood
disorder.
• Different mood disorders affect people in different ways.
Understanding the specifics of common disorders is helpful
for people with a friend or family member living with a
mood disorder.

4. What are Mood Disorders?
Mood disorders are changes or abnormalities in
mood that interfere with a person’s ability to live
their everyday life. While it’s common to
experience a range of emotions throughout the
day, until it interferes with day-to-day life.

5. Statistics on Mood Disorders
• Mood disorders are among the most commonly diagnosed
mental health conditions. Reviewing mood disorder
statistics highlights the prevalence of these disorders.
• The average age of onset for bipolar disorder is 25, but it
may occur earlier
• Bipolar disorder affects men and women equally
• Approximately 2.6 percent of the population is diagnosed
with bipolar disorder.

6. CONT……
• Nearly 7 percent of American adults report having experienced
a depressive episode related to major depressive disorder in the
past year
• One percent or less of the population experiences cyclothymia
• As many as 50 percent of people who experience cyclothymia
will later develop a bipolar disorder
• Most women with PMDD also have another primary mental
health diagnosis
• PMDD affects 5 percent of women with menstrual periods

7. Types of mood disorder
A- Depressive disorder :
1. Major depressive disorder
2. Persistent depressive disorder (Dysthymia)
3- Disruptive mood dysregulation disorder
4- Premenstrual dysphoric disorder
B- Bipolar Spectrum Disorder
1. Bipolar (I)disorders
2. Bipolar (II) disorders.
3. Cyclothymic disorder

8. Major Depressive Disorder
Depression is a mood disorder that causes a persistent feeling
of sadness and loss of interest. Also called major depressive
disorder or clinical depression, it affects how you feel, think
and behave and can lead to a variety of emotional and physical
problems. You may have trouble doing normal day-to-day
activities, and sometimes you may feel as if life isn't worth
living.

9. Cont., Major Depressive Disorder
• According to the DSM-5, Although depression may occur only once
during your life, people typically have multiple episodes. During these
episodes, five or more of the symptoms must be present for a 2-week period,
symptoms occur most of the day, nearly every day and may include must
occur almost every day, and must be severe in nature
at least one of the symptoms is either
(1) depressed mood or
(2) loss of interest or pleasure

10. Symptoms of MDD
• Feelings of sadness, tearfulness, emptiness or hopelessness
• Angry outbursts, irritability or frustration, even over small
matters
• Loss of interest or pleasure in most or all normal activities,
such as sex, hobbies or sports
• Sleep disturbances, including insomnia or sleeping too much
• Tiredness and lack of energy, so even small tasks take extra
effort
• Reduced appetite and weight loss or increased cravings for
food and weight gain
• Anxiety, agitation or restlessness
• Slowed thinking, speaking or body movements

11. • Feelings of worthlessness or guilt, fixating on past failures or
self-blame
• Trouble thinking, concentrating, making decisions and
remembering things
• Frequent or recurrent thoughts of death, suicidal thoughts,
suicide attempts or suicide
• Unexplained physical problems, such as back pain or
headaches
For many people with depression, symptoms usually are severe
enough to cause noticeable problems in day-to-day activities,
such as work, school, social activities or relationships with
others. Some people may feel generally miserable or unhappy
without really knowing why.

12. Types of depression
Symptoms caused by major depression can vary from person to person. To clarify the
type of depression, may add one or more specifiers.
– A specifier means that clint have depression with specific
features, such as:
• Anxious distress — depression with unusual restlessness or worry
about possible events or loss of control
• Mixed features — simultaneous depression and mania, which
includes elevated self-esteem, talking too much and increased
energy
• Melancholic features — severe depression with lack of response to
something that used to bring pleasure and associated with early
morning awakening, worsened mood in the morning, major changes
in appetite, and feelings of guilt, agitation or sluggishness

13. CONT….
• Atypical features — depression that includes the ability to temporarily
be cheered by happy events, increased appetite, excessive need for
sleep, sensitivity to rejection, and a heavy feeling in the arms or legs
• Psychotic features — depression accompanied by delusions or
hallucinations, which may involve personal inadequacy or other
negative themes
• Catatonia — depression that includes motor activity that involves
either uncontrollable and purposeless movement or fixed and inflexible
posture
• Peripartum onset — depression that occurs during pregnancy or in
the weeks or months after delivery (postpartum)
• Seasonal pattern — depression related to changes in seasons and
reduced exposure to sunlight

14. Other disorders that cause depression
symptoms
Several other disorders, such as those below, include depression as a
symptom. It's important to get an accurate diagnosis, so you can get
appropriate treatment.
• Bipolar I and II disorders. These mood disorders include mood swings
that range from highs (mania) to lows (depression). It's sometimes
difficult to distinguish between bipolar disorder and depression.
• Cyclothymic disorder. Cyclothymic (sy-kloe-THIE-mik) disorder
involves highs and lows that are milder than those of bipolar disorder.
• Disruptive mood dysregulation disorder. This mood disorder in
children includes chronic and severe irritability and anger with frequent
extreme temper outbursts. This disorder typically develops into
depressive disorder or anxiety disorder during the teen years or
adulthood.

15. CONT……
• Persistent depressive disorder. Sometimes called dysthymia (dis-
THIE-me-uh), this is a less severe but more chronic form of depression
symptoms present at least 2 years. While it's usually not disabling,
persistent depressive disorder can prevent you from functioning
normally in your daily routine and from living life to its fullest.
• Premenstrual dysphoric disorder. This involves depression
symptoms associated with hormone changes that begin a week before
and improve within a few days after the onset of your period, and are
minimal or gone after completion of your period.
• Other depression disorders. This includes depression that's caused by
the use of recreational drugs, some prescribed medications or another
medical condition.

16. • Postpartum depression
• Severe depression beginning within 4 weeks of giving birth.
• Most often occurs in women with underlying or preexisting
mood or other psychiatric disorder.
• Symptoms
• range from marked insomnia, and fatigue to suicide.
• Homicidal and delusional beliefs about the baby may be
present. Can be psychiatric emergency, with both mother and
baby at risk.
• A patient suffering from this disorder needs intensive
treatment with medications and psychotherapy.

17. •Deferential between DSM-5 & ICD-11 in
Depression

18. Risk factors
Depression often begins in the teens, 20s or 30s, but it can happen
at any age. More women than men are diagnosed with depression,
but this may be due in part because women are more likely to seek
treatment.
• Factors that seem to increase the risk of developing
or triggering depression include:
• Certain personality traits, such as low self-esteem and being
too dependent, self-critical or pessimistic
• Traumatic or stressful events, such as physical or sexual
abuse, the death or loss of a loved one, a difficult relationship,
or financial problems
• Blood relatives with a history of depression, bipolar disorder,
alcoholism or suicide

19. • Being lesbian, gay, bisexual or transgender, or having
variations in the development of genital organs that aren't
clearly male or female (intersex) in an unsupportive
situation
• History of other mental health disorders, such as anxiety
disorder, eating disorders or post-traumatic stress disorder
• Abuse of alcohol or recreational drugs
• Serious or chronic illness, including cancer, stroke,
chronic pain or heart disease
• Certain medications, such as some high blood pressure
medications or sleeping pills (talk to your doctor before
stopping any medication)

20. Etiological Factors of Depressive Disorders
A. Neurotransmitters
Many theories attempt to explain the cause of depression; however,
basically depression is thought to involve changes in receptor-
neurotransmitter relationships in the following areas of the brain:
• 1. Limbic system (emotional alterations)
• 2. Prefrontal cortex (decreased mood, problems concentrating)
• 3. Hippocampus (memory impairments; feelings of worthlessness,
hopelessness, and guilt)
• 4. Amygdala (anxiety and reduced motivation)

21. Serotonin
• Serotonin depletion occurs in depression; thus,
serotonergic agents are effective treatments.
• Some patients with suicidal impulses have low
cerebrospinal fluid (CSF) concentrations of serotonin
metabolites (5- hydroxyindole acetic acid [5-HIAA]) and
low concentrations of serotonin uptake sites on platelets.
• Serotonin circuit dysfunction can result in
(poor impulse control, low sex drive, decreased appetite,
disturbed regulation of body temperature, and
irritability).

22. Cont., Neurotransmitters
• Norepinephrine.
• Abnormal levels (usually low) of norepinephrine metabolites
(3-methoxy-4-hydroxyphenylglycol [MHPG]) are found in
blood, urine, and CSF of depressed patients.
• Decreased levels of NE in the medial forebrain bundle
(MFB) may account for anergia, anhedonia, decreased
concentration, and diminished libido in depression.

23. Cont., Neurotransmitters
• Dopamine.
• Dopamine activity may be reduced in depression . Drugs that reduce
dopamine concentrations (e.g., reserpine) and diseases that reduce
dopamine concentrations (e.g., Parkinson’s disease) are associated with
depressive symptoms. Drugs that increase dopamine concentrations,
such as amphetamine reduce the symptoms of depression.
• Two recent theories about dopamine and depression are that the
mesolimbic dopamine pathway may be dysfunctional in depression
and that the dopamine D1 receptor may be hypoactive in depression.
• Dopamine play a role in the reward and incentive behavior
processes, emotional expression, and learning processes that are
disrupted in depression.

24. • N.B
• Serotonin and norepinephrine are also involved in the
perception of pain by modifying the effects of substance P,
glutamate, GABA, and other pain mediators. There is
considerable overlap in the biological underpinnings of both
major depression and chronic pain.
• In some cases chronic painful physical conditions (CPPCs)
such as backaches or headaches may be due to MDD rather
than chronic pain, and in some cases these conditions may
present as the only sign of depression

25. Cont., Etiological Factors of Depressive
Disorders
• B- Genetic Factors
• Twin studies
Genetic factors play a role in the development of depressive
disorders. Various studies reveal that the average concordance
rate for unipolar depression mood disorders among
monozygotic twins is 50%. The percentage for dizygotic twins
(different genetic constitution) is 20%.

26. • Genetic Factors
• Adoptive studies
The risk for the development of depression in children born to
parent with a depressive illness is the same when these children are
adopted by a non depressive family. Most studies are supportive of a
genetic link concluding that mood disorders are heritable for some
people
• Increased heritability is associated with an earlier age of onset,
greater rate of comorbidity (especially alcoholism and psychosis),
and increased risk of recurrent illness.

27. Cont., Etiological Factors of Depressive
Disorders
• C. Psychosocial
• 1. Psychoanalytic.
Freud described internalized ambivalence toward a love object
(person), which can produce a pathologic form of mourning if the
object is lost or perceived as lost. This 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.

28. • Cont., Psychosocial
• 2. Psychodynamics.
In depression, introjection of ambivalently viewed lost objects
leads to an inner sense of conflict, guilt, pain, and loathing; a
pathologic mourning becomes depression as ambivalent
feelings meant for the introjected object are directed at the self.

29. Cont., Psychosocial
• 3. Cognitive theory.
Aaron T. Beck, proposed that people acquire a psychological
predisposition to depression through early life experiences. These
experiences contribute to negative, illogical, and irrational thought
processes that may remain dormant until they are activated during
times of stress.
Beck found that depressed people process information in negative
ways, even in the midst of positive factors that affect the person’s
life.
Beck believed that three automatic negative thoughts—called
Beck’s cognitive triad—are responsible for the development of
depression

30. Cognitive triad of Aaron Beck:
1. A negative, self-deprecating view of self: “I really never do
anything well; everyone else seems smarter.”
2. A pessimistic view of the world: “Once you’re down, you can’t
get up. Look around, poverty, homelessness, sickness, war, and
despair are every place you look.”
3. The belief that negative reinforcement (or no validation for the
self) will continue: “It doesn’t matter what you do; nothing ever gets
better.

31. • Cont., Psychosocial
• 4. Learned helplessness.
• Martin Seligman’s theory is that of learned helplessness, stated that
although anxiety is the initial response to a stressful situation,
anxiety is replaced by depression if the person feels no control over
the outcome of a situation.
• People who believe that an undesired event is their fault and that
nothing can be done to change it are prone to depression.
• The theory of learned helplessness has been used to explain the
development of depression in certain social groups, such as older
adults, people living in impoverished areas, and women.

32. • Cont., Psychosocial
• 5. Stressful life events.
• The Stress-Diathesis Model of Depression is a psychological theory that
explains depression from an environmental, interpersonal, and life-events
perspective combined with biological predisposition (diathesis).
• It is well-known that psychosocial stressors and interpersonal events
trigger certain neurophysical and neurochemical changes in the brain.
• Because norepinephrine, serotonin, and acetylcholine play a role in stress
regulation, when these neurotransmitters become overtaxed through
stressful events, neurotransmitter depletion may occur and cause
permanent neuronal damage, leaving the person vulnerable to depression
later in life

33. Clinical features
• 1. Information obtained from history
a. Depressed mood: subjective sense of sadness, feeling
“blue” or “down in the dumps” for a prolonged period of time.
b. Anhedonia: inability to experience pleasure.
c. Social withdrawal.
d. Lack of motivation, little tolerance of frustration.

34. e. Vegetative signs.
 Loss of libido.
 Weight loss and anorexia.
 Weight gain and hyperphagia.
 Low-energy level; fatigability.
 Abnormal menses.
 Diurnal variation (symptoms worse in morning).
 Early morning awakening (terminal insomnia)
f. Constipation.
g. Dry mouth.
h. Headache

35. Cont., Clinical features
2. Information obtained from mental status examination
• a. General appearance and behavior. Psychomotor retardation or
agitation, poor eye contact, tearful, inattentive to personal
appearance.
• b. Affect. Constricted or labile.
• c. Mood. Depressed, irritable, frustrated, sad.
• d. Speech. Little or no spontaneity; monosyllabic; long pauses; soft,
low monotone.

36. • e. Thought content. Suicidal ideation affects 60% of depressed
patients, and 15% commit suicide; pervasive feelings of
hopelessness, worthlessness, and guilt; somatic preoccupation;
indecisiveness; poverty of thought content and mood-congruent
hallucinations and delusions.
• f. Cognition. Distractible, poor memory, apparent
disorientation; abstract thought may be impaired.
• g. Insight and judgment. Impaired because of cognitive
distortions of personal worthlessness.

37. • Cont., Clinical features
• 3. Associated features
• a. Somatic complaints may mask depression: in particular,
cardiac, gastrointestinal, and genitourinary symptoms; low back
pain, other orthopedic complaints.
• b. Content of delusions and hallucinations, when present,
tends to be
-Congruent with depressed mood; most common are delusions
of guilt, poverty, and deserved persecution, in addition to
somatic and nihilistic (end of the world) delusions .

38. • Cont., Clinical features
• 4. Age-specific features.
Depression can present differently at different ages.
• a. Prepubertal. Somatic complaints, agitation, single-voice
auditory hallucinations, anxiety disorders, and phobias.
• b. Adolescence. Substance abuse, antisocial behavior,
restlessness, school difficulties, increased sensitivity to rejection,
poor hygiene.
• c. Elderly. Cognitive deficits (memory loss, disorientation,
confusion); pseudodementia or the dementia syndrome of
depression, apathy, and distractibility.

39. Course and Prognosis of Depressive disorder
• 50% of depressed patients eventually commit suicide.
• At least 75% of affected patients have a second episode of
depression, usually within the first 6 months after the initial
episode.
• The average number of depressive episodes in a lifetime is five.

40. • Prognosis generally is good: 50% recover,30% partially
recover, 20% have a chronic course.
• About 20% to 30% of dysthymic patients develop, in
descending order of frequency, major depressive disorder
(called double depression), bipolar II disorder, or bipolar I
disorder.

41. Complications associated with depression include:
• Excess weight or obesity, which can lead to heart disease
and diabetes
• Pain or physical illness
• Alcohol or drug misuse
• Anxiety, panic disorder or social phobia
• Family conflicts, relationship difficulties, and work or
school problems
• Social isolation
• Suicidal feelings, suicide attempts or suicide
• Self-mutilation, such as cutting
• Premature death from medical conditions

42. Prevention
• There's no sure way to prevent depression. However,
these strategies may help.
• Take steps to control stress, to increase patient
resilience and boost his self-esteem.
• Reach out to family and friends, especially in times
of crisis, to help weather rough spells.
• Get treatment at the earliest sign of a problem to
help prevent depression from worsening.
• Consider getting long-term maintenance
treatment to help prevent a relapse of symptoms.

43. • Treatment of Depressive Disorder
Psychopharmacology
• Antidepressant drugs can positively alter :-
• poor self-concept,
• degree of withdrawal,
• vegetative signs of depression,
• activity level.

44. Types of Antidepressant Medication
• Selective Serotonin Reuptake Inhibitors.
 Prozac is the first selective serotonin reuptake inhibitor
(SSRI).
 Essentially, the SSRIs selectively block the neuronal uptake
of serotonin, thereby leaving more serotonin available at the
synaptic site.

45. • Indications of SSRIs.
Depressive disorders
Anxiety disorders, in particular, obsessive-
compulsive disorder and panic disorder
 Bulimia nervosa.

46. • Potential toxic effects of SSRIs.
 Serotonin syndrome
Is a life-threatening event that related to over activation of
the central serotonin receptors, caused either by too high a
dose or by interaction with other drugs.

47. Symptoms of serotonin syndrome include
• Abdominal pain, &diarrhea,
• Sweating, & fever
• Tachycardia, & elevated blood pressure
• Altered mental state (delirium)
• Myoclonus (muscle spasms)
• Increased motor activity, irritability
• Cardiovascular shock, or death.

48. Tricyclic Compounds
.e.g (Tofranil, Norpramin)
.TCAs Inhabit the reuptake of norepinephrine and serotonin by the
presynaptic neurons in the C.N.S.
Common adverse reactions.
1-Anticholinergic side effects
usually not serious and are often transitory, but urinary retention and
severe constipation warrant immediate medical attention.
2-Postural orthostatic hypotension
3-Tachycardia

49. Serotonin Norepinephrine Reuptake Inhibitors
(SNRI)
e.g. (Effexor, Cymbalta)
Indication
-Major depressive disorder
-Anxiety disorders
-Attention deficit hyperactivity disorder
-Menopausal symptoms
.

50. • Monoamine Oxidase Inhibitors.
• MAOIs are second-line medications but have proven
benefits for patients who have not responded to other
medications or to ECT treatment.
e.g. Nardil , Marplan

51. N.B
• MAOIs inhibit the breakdown of tyramine in the liver.
• So, increased levels of tyramine can lead to high blood
pressure, hypertensive crisis, and eventually cerebrovascular
accident and death.
• Therefore people taking MAOIs must restrict their intake of
tyramine, it (found in various foods and beverages such as
cheese and red wine)

52. • Contraindications of MAOIs
• Cerebrovascular disease
• Hypertension and congestive heart failure
• Liver disease
• Consumption of foods containing tyramine, tryptophan, and
dopamine
• Age younger than 16 years

53. 2. Psychological Therapy.
a. Cognitive Therapy
Is aimed at testing and correcting negative cognitions and the
unconscious assumptions that underlie them; based on correcting
chronic distortions in thinking that lead to depression.
• b. Behavioral Therapy
Based on learning theory (classic and operant conditioning).
positive reinforcement may be an effective in the treatment of
depression.

54. • c. Group psychotherapy.
Depressed patients may benefit from support, ventilation, and
positive reinforcement of groups, and from interpersonal
interaction and immediate correction of cognitive and
transference distortions by other group members.
d. Family therapy .
Particularly indicated when patient’s depression is disrupting
family stability, when depression is related to family events, or
when it is supported or maintained by family patterns.

55. • 3- Brain Stimulation Therapies
A-Electroconvulsive therapy.
Electroconvulsive therapy (ECT) is most effective treatment of:
1- Major depression with psychotic symptoms,
2- Life-threatening psychiatric conditions (e.g., self-harm).
3- Treatment- Resistant (TR) depression
-Treatment resistant depression exists when pharmacological
interventions fail or when the side effects are too uncomfortable.

57. • Potential adverse reactions.
-Confusion
-Disorientation .
-Memory deficits for the first few weeks after treatment
ECT is safe and effective, and can achieve a 70% to 90%
remission rate in depressed patients within 1 to 2 weeks.
Maintenance ECT (once a week to once a month) help to
decrease relapse rates for patients with recurrent depression.

58. B-Vagus nerve stimulation.
VNS indicated for patients with treatment-resistant
depression (TRD)
-VNS involves surgically implanting a device called a pulse
generator into the upper left chest. The pulse generator is
connected by a wire to the left vagus nerve; when the generator is
stimulated electrical impulses are transmitted to areas of the brain
that affect mood centers. When successful, there is an
improvement of depressive symptoms.

59. 3-Rapid trans-cranial magnetic stimulation (rTMS).
 rTMS is electromagnetism, deliver an electrical field to the
cerebral cortices, the waves do not result in generalized seizure
activity.
 An electrical magnetic coil is placed on the scalp, pulsed high-
intensity current passes through the coil, creating powerful
magnetic fields that change the way brain cells function.
 Daily treatments last for approximately 40 minutes

60. • Bipolar Spectrum Disorder
• The DSM-5 calls these groups of disorders Bipolar and
Related Disorders.
• The term formerly used for these disorders: manic
depressive illness.
• Bipolar disorders are chronic, recurrent, and life-
threatening illnesses that require lifetime monitoring.

61. • BSDs are characterized by two opposite poles.
• One pole is mania (or hypomania), which constitutes an
elevated, expansive, or irritable mood, accompanied by a
persistent increase in activity and/ or energy.
• The other pole is depression.

62. • Types of Bipolar disorder
1- Bipolar I disorder:
• At least one episode of mania, most often alternating with
major depressive episodes.
• Psychosis may accompany the manic episode, and
hospitalization may be warranted.

63. • 2- Bipolar II disorder:
• Hypomanic episode(s) alternating with at least one major
depressive episode.
• Psychosis is not present in bipolar II.
• Bipolar II disorder is no less serious than bipolar I
disorder, as both disorders are typically accompanied by
serious impairment in work and social functioning

64. • 3- Cyclothymia:
• Hypomanic episodes alternating with minor
depressive episodes (at least 2 years in duration).

65. • Other types of bipolar disorder
Rapid cycling bipolar disorder
• Four or more mood episodes in a 12-month period.
Mania or hypomania with mixed features
• Is used when a patient in a full bipolar or hypomanic mood
displays at the same time depressive symptoms.

66. Symptoms of manic episode
1. An elevated, expansive, or irritable mood
2. Increased self-esteem or grandiosity
3. Less need for sleep (2–3 hours)
4. Very talkative
5. Racing thoughts
6. Easily distracted and unable to focus
7. Excessive spending and engaging in pleasurable activities
8. Severe impairment in occupational and social functioning

67. • Cont., Manic episode
• The distinct Manic episode lasting at least for
one week

68. Symptoms of hypomanic episode
The same as Manic episode BUT
 The episode is not severe enough to cause marked impairment
in social or occupational functioning or to necessitate
hospitalization.
 The episode is not accompanied by psychotic features and If
there are psychotic features, the episode is defined by manic
episode.
 The distinct period of hypomanic episode lasting at least 4
days.

69. Etiological Factors
• Genetic Factors
• Twin, family, and adoption studies provide significant evidence
to support the view that bipolar disorders have a strong genetic
component.
• Identical twins have greater risk (33% to 90%) than non
identical twins (18% to 35%).
• First-degree relatives are seven times more likely to develop
bipolar disorder than people in the general population.

70. • Neurobiological Factors
• Neurotransmitters
• During a manic episode, patients demonstrate significantly
higher plasma levels of norepinephrine, epinephrine and
dopamine
• Neuroanatomical Factors
• MRI scans identify reduced volumes in the hippocampus, medial
orbital cortex, and anterior cingulum
• Dysregulation in the neurocircuits surrounding subregions of the
prefrontal cortex (PFC) and medial temporal lobe (MTL).

71. • Psychosocial Factors
• 1. Psychoanalytic.
• Mania and elation are viewed as defense against underlying
depression.
• 2. Psychodynamics
• Feelings of inadequacy and worthlessness are converted by
means of denial, reaction formation, and projection to grandiose
delusions.
• 3. Stressful life events
• Family atmosphere suggests an association between high
expressed emotion and relapse.

72. Course and Prognosis
• Mania may begin gradually over the course of a few weeks, but
more typically it has an abrupt onset.
• A major mood disorder, usually bipolar II disorder, develops in
about 30% of patients with cyclothymic disorder.
• Forty-five percent of manic episodes recur.
• Untreated, manic episodes last 3 to 6 months, with a high rate
of recurrence.

73. • Treatment
• During the acute phase, medications are vital to bring the patient to
a safe physical and psychological level of functioning.
• Also, for many patients medication is a lifelong protection against
relapse.

74. • A- Psychopharmacology
• Lithium carbonate (LiCO3)
• LiCO3 is effective in the acute treatment of acute mania and
the prevention of its recurrent.
• Lithium aborts 60% to 80% of acute manic and hypomanic
episodes within 10 to 21 days.
• Lithium is less effective in people with mixed mania (elation
and depression), and those with rapid cycling.

75. • Cont., (LiCO3)
• For acute mania, lithium blood level would be 0.6 to 1.2 mEq/L.
• For maintenance therapy, lithium levels should range from 0.4 to
1.0 mEq/L; however, levels of 0.6 to 0.8 mEq/L are effective for
most.
• Levels higher than 1.5 mEq/L can result in significant toxicity.

76. • Cont., (LiCO3)
 Major long-term risks of lithium therapy
• Hypothyroidism
• Kidneys’ impairment

77. • (2)Anticonvulsant
• Anticonvulsants are medications used to treat seizures, and in
addition, some are also used in bipolar disorder as mood
stabilizers.
• These medications work in bipolar disorder by Enhancing the
effect GABA

78. E.g. of Anticonvulsant
• Valporic acid /Valporate (Depakote)
• -Carbamazepine (Tegratole)
• -Lamotrigine (Lamictal)

79. • Indications of anti-convulsant
• Beneficial in controlling mania (within 2 weeks)
• Superior in dysphoric mania
• Superior in rapid cycling

80. • Cont., Anticonvulsant
• Sever adverse effect of anti-convulsant drugs
1-Valporic acid
• Hepatic failure resulting in fatality.
• Teratogenic effects such as neural tube defects (e.g.,
spina bifida).
• Life-threatening pancreatitis .

81. • 2-Carbamazepine
• Cause aplastic anemia and agranulocytosis
3-Lamotrigine
• Aseptic meningitis is rare but serious side effect
• Serious rashes requiring hospitalization including Stevens-
Johnson syndrome and, rarely, life-threatening Toxic Epidermal
Necrolysis

82. • Anxiolytics
Clonazepam (Klonopin) lorazepam (Ativan).
• Indicated in
Acute mania in some patients with treatment-resistant mania.
Psychomotor agitation
They should be avoided in patients with a history of substance
abuse.

83. • Second-Generation Antipsychotics
• Olanzapine (Zyprexa) Risperidone (Risperdal)
• Aripiprazole (Abilify) Ziprasidone (Geodon)
Second generation antipsychotics show to be effective in
relief of the following symptoms
- Insomnia
- Anxiety
- Agitation

84. • 2- Electroconvulsive Therapy
• Indicated for P.T with BPD in the following cases
• Treatment resistant mania
• Rapid cycling features.
• Paranoid destructive features (who often respond poorly to
lithium therapy)
• Suicidal attempt.

85. • 3- Psychotherapy
• CBT
• a. Cognitive. Has been studied in relation to increasing
compliance with lithium therapy among patients with bipolar
disorder.
• b. Behavioral. Helps to set limits on impulsive or inappropriate
behavior through such techniques as positive and negative
reinforcement.

86. • Interpersonal therapy.
• The interpersonal focus on resolutions of interpersonal
problems (e.g., unresolved grief) and prevention of further
disputes.
• It is effective in acute and maintenance phases of
treatment.

87. • Family-focused therapy.
• Family therapy, is effective to
help families stay together
lower rates of hospitalization
improve family functioning.
• Family-focused therapy (FFT) including:
Psychoeducation
Relapse prevention
Ways to make the diagnosis of bipolar disorder more acceptable
to the patient

88. • Group Therapy.
Can be helpful in challenging denial and defensive grandiosity .
 Useful in addressing such common issues among manic
patients as (inadequacy, fear of mental illness, and loss of
control).
Helpful I reintegrating patients socially.

89. • Differential Diagnosis of Mood Disorder
• A. Mood disorder resulting from general medical condition.
(e.g., brain tumor, metabolic illness, HIV disease, Parkinson’s
disease) Cognitive deficits are common.
• B. Substance-induced mood disorder
• (e.g., cocaine, amphetamine, propranolol), Must always be
ruled out for diagnosis of mood disorder

90. • Differential Diagnosis of Mood Disorder
• C. Schizophrenia.
• Schizophrenia can look like a manic, major depressive, or mixed
episode with psychotic features.
• Depressive-like or manic-like episode with presence of mood-
incongruent psychotic features suggests schizophrenia.
• Thought insertion and broadcasting, loose associations, poor
reality testing, or bizarre behavior may also suggest
schizophrenia.

91. • Differential Diagnosis of Mood Disorder
• D. Grief.
• Differentiated from major depressive disorder by absence of
suicidal ideation or profound feelings of hopelessness and
worthlessness.
• Usually resolves within a year.
• May develop into major depressive episode in predisposed
persons.

92. • Differential Diagnosis of Mood Disorder
• E. Personality disorders.
Lifelong behavioral pattern associated with rigid defensive style;
depression may occur after stressful life event because of inflexibility
of coping mechanisms.
Manic episode may also occur in predisposed people with pre-
existing personality disorder.
A mood disorder may be diagnosed on Axis I simultaneously with a
personality disorder on Axis II.

93. • Differential Diagnosis of Mood Disorder
• F. Schizoaffective disorder.
• Signs and symptoms of schizophrenia accompany prominent mood
symptoms. Course and prognosis are between those of schizophrenia
and mood disorders.
• g. Primary sleep disorders.
 Distinguish from major depression by assessing for typical signs and
symptoms of depression and occurrence of sleep abnormalities only in
the context of depressive episodes.