Mood Disorders

Mood Disorders

Mood is a persons subjective persistent emotional state Affect is the objective appearance of mood category of mental disorders in which significant and chronic disruption in mood is the predominant symptom, causing impaired cognitive , behavioral, and physical functioning

Depressive Disorders

Major Depressive Disorder Dysthymic Disorder

Bipolar Disorders

Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder

A History of Bipolar Disorder A History of Bipolar Disorder

You may not have known that Bipolar Disorder is actually one of the worlds oldest diseases. Using early medical records, researchers have found symptoms of this disease recorded from since the second century. Aretaeus of Cappadocia (a medical philosopher) first recognized and linked symptoms of mania and depression, but his findings were ignored. Then, in 1650, scientist Richard Burton wrote a book called The Anatomy of Melancholia. Even today, he is credited as being the founding father of depression as a mental illness. Others who made significant findings in the field of this illness include:
Jules Falret (1854), established a link between depression and suicide Francois Baillarger, characterized distinction between bipolar disorder and schizophrenia Emil Krappelin (1913), established the term manic-depressive

The National Association of Mental Health (NAMI) was founded in 1979. A lot of significant research was done in 1980, and included findings like the distinguishment between adult and childhood bipolar disorder. Even today, methods for treating bipolar disorder are still being tested and probable causes being researched.

German psychiatrist Emil Kraepelin (18561926)

is one of the most recognizable names in the history of bipolar. He is sometimes referred to as the founder of modern scientific psychiatry and psychopharmacology. In the early 1900s, after extremely detailed research, he formulated the separate terms manic-depression and dementia praecox.

history

Sigmund Freud broke new ground when he used psychoanalysis with his manic-depressive patients: biology then took a back seat. He implicated childhood trauma and unresolved developmental conflicts in bipolar disorder. In the early 1950s, German psychiatrist Karl Leonhard and colleagues initiated the classification system that led to the term bipolar, differentiating between unipolar and bipolar depression.

DSM-IV Diagnostic Categories

Major Depression Dysthymia Depressive Disorder NOS Bipolar Disorder, Type I or II Cyclothymia Bipolar Disorder NOS

Mood Disorder secondary to GMC Substance-Induced Mood Disorder

EPIDEMIOLOGY

Major Depressive Episode (building block)

A. During the same 2-week period, five or more of the following symptoms including either 1 or 2 have been present (must be a change in functioning)
1. 2. 3. 4. 5. 6. 7. 8. 9.

Depressed mood most of the day, nearly everyday Diminished interest or pleasure in all, or almost all, activities Significant changes in appetite and/or weight Significant changes in sleep patterns Psychomotor retardation or agitation Fatigue or loss of energy Feelings of worthlessness or inappropriate guilt Diminished ability to concentrate or make decisions Recurrent thoughts or death or suicide

Major Depressive Episode (building block)

B. The criteria do not meet criteria for a Mixed Episode C. The symptoms cause clinically significant distress or impairment in functioning D. Not due to a GMC or substance E. The symptoms are not better accounted for by Bereavement

The Symptoms of Depression

In primary care, physical symptoms are often the chief complaint in depressed patients

In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief compliant1

N = 1146 Primary care patients with major depression

Bereavement (mourning)

Normal reaction to the loss of a loved one May have several depressive symptoms Consider diagnosis of major depressive episode if:

Symptoms persist > 2 months after loss Presence of any of the following:

Guilt (except for actions taken or not taken at time of death) Profound and persistent anhedonia Marked psychomotor retardation Decreased self-esteem Suicidal ideation Hallucinations other than hearing voice or seeing image of deceased person

Major Depressive Disorder

One or more Major Depressive Episodes AND No history of mania or hypomania or mixed episode Many patients given the diagnosis of MDD reveal past episodes of manic or hypomanic behavior Specify:

Single Episode

Recurrent : 2 major depression episodes, separated by at least a 2 month period with more or less normal functioning/mood (with or without full interepisode recovery)

Major Depression: Interepisode Recovery

Recurrent, Full Interepisode Recovery

Recurrent, Without Full Interepisode Recovery

Major Depressive Disorder

Major Depressive Episode

Major Depressive Episode

Major Depressive Episode

Major Depressive Episode

MDD, single episode

MDD, recurrent episodes

Time Course of MDD

Often lasts for a year without treatment Chances increase by 50% for another episode after current episode (i.e. high relapse and recurrence rates) Many go on to experience chronic depression (>2Y duration) (but may be a result of inadequate treatment)

Likelihood of having another Major Depressive Episode if youve had

1 episode 50% 2 episodes 70% 3 episodes 90%

Major Depressive Episode

Major Depressive Episode

Major Depressive Episode

Major Depressive Episode

Major Depressive Episode

Major Depressive Episode

MDE specifiers

Psychotic features: Mood congruent/incongruent

hallucinations/delusions

Melancholic features: Loss of pleasure, lack of reactivity to pleasurable

or echopraxia

stimuli, depression that is worse in the morning, early morning awakening, excessive guilt, weight loss.

Catatonic features: Motoric immobility, extreme agitation, negativism, echolalia

Atypical Oversleep, overeat, gain weight, and are anxious

Postpartum onset :within 4 weeks of child birth Chronic (>2 years duration) Seasonal pattern (Seasonal Affective Disorder [SAD] or winter
depression) Weather episodes are more likely during a certain season
Longitudinal course (with or without interepisode recovery )

Psychotic features

Presence of psychotic features reflect severity of

disease and a poor prognostic indicator Categorized as mood congruent : in hormony with mood example guilt
mood incongruent

Melancholic features
One of the oldest terms in psychiatry, dating back to hippocrates in 4th century Associated with changes in autonomic nervous system and endocrine function, for that reason the term endogenous depression appears . It describe sever anhedonia, late insomnia, loss of weight, profound feeling of guilt, suicidal ideation.

Melancholic Features Specifier for Mood Disorders

Specify if: With Melancholic Features (can be applied to the current or most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or Bipolar II Disorder only if it is the most recent type of mood episode) A. Either of the following, occurring during the most severe period of the current episode: (1) loss of pleasure in all, or almost all, activities (2) lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens) B. Three (or more) of the following: (1) distinct quality of depressed mood (i.e., the depressed mood is experienced as distinctly different from the kind of feeling experienced after the death of a loved one) (2) depression regularly worse in the morning (3) early morning awakening (at least 2 hours before usual time of awakening) (4) marked psychomotor retardation or agitation (5) significant anorexia or weight loss (6) excessive or inappropriate guilt

Catatonic Features Specifier for Mood Disorders

The clinical picture is dominated by at least two of the following: (1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor (2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli) (3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism (4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing (5) echolalia or echopraxia

Atypical features
Reffered to reversed vegitative symtoms younger age of onset,more sever psychomotor slowing, more frequent association with panic disorder and substance abuse.

Atypical Features Specifier for Mood Disorders

Specify if: With Atypical Features (can be applied when these features predominate during the most recent 2 weeks of a Major Depressive Episode in Major Depressive Disorder or in Bipolar I or Bipolar II Disorder when the Major Depressive Episode is the most recent type of mood episode, or when these features predominate during the most recent 2 years of Dysthymic Disorder) A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events) B. Two (or more) of the following features: (1) significant weight gain or increase in appetite (2) Hypersomnia (3) leaden paralysis (i.e., heavy, leaden feelings in arms or legs) (4) long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment

Criteria for Seasonal Pattern Specifier for Mood Disorders

Specify if: With Seasonal Pattern (can be applied to the pattern of Major Depressive Episodes in Bipolar I Disorder, Bipolar II Disorder, or Major Depressive Disorder, Recurrent) A. There has been a regular temporal relationship between the onset of Major Depressive Episodes in Bipolar I or Bipolar II Disorder or Major Depressive Disorder, Recurrent, and a particular time of the year (e.g., regular appearance of the Major Depressive Episode in the fall or winter). Note: Do not include cases in which there is an obvious effect of seasonal-related psychosocial stressors (e.g., regularly being unemployed every winter). Full remissions (or a change from depression to mania or hypomania) also occur at a characteristic time of the year (e.g., depression disappears in the spring). C. In the last 2 years, two Major Depressive Episodes have occurred that demonstrate the temporal seasonal relationships defined in Criteria A and B, and no nonseasonal Major Depressive Episodes have occurred during that same period. D. Seasonal Major Depressive Episodes (as described above) substantially outnumber the nonseasonal Major Depressive Episodes that may have occurred over the individual's lifetime.

Dysthymia
A. Depressed mood most of the day, more days than not, for at least 2 years 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 C. During the 2-year period, the person has never been without

the symptoms for more than 2 months at a time

Dysthymia
D. Not better accounted for by Major Depressive Disorder E. There has never been a Manic, Mixed, or Hypomanic episode

F. Not better accounted for by another disorder

G. Not due to a GMC or substance H. Symptoms cause clinically significant distress or impairment in functioning

Major Depression vs. Dysthymia

Recurrent Major Depressive Episodes

Dysthymia

The Depressive disorder NOS

disorders with depressive features that do not meet the criteria for Major

Depressive Disorder, Dysthymic disorder, Adjustment Disorder with Depressed Mood or Adjustment Disorder with Mixed Anxiety and Depressed Mood. Sometimes depressive symptoms can present as part of an
Anxiety Disorder Not otherwise Specified.

Premenstrual Dysphoric Disorder: in most menstrual cycles during the

past years, (e.g., markedly depressed mood, marked anxiety, marked affective lability, or decreased interest in activities) regularly occurred during the onset of menses. These symptoms must be severe enough to markedly interfere with work, school, or usual activities and be entirely absent for at least 1 week post menses. Minor depressive disorder: episodes of at at least 2 weeks of depressive symptoms but with fewer than the five items required for Major Depressive Disorder.

The Depressive disorder NOS

Recurrent brief depressive disorder: depressive episodes

lasting from 2 days up to 2 weeks, occurring at least once a month for 12 months(not associated with the menstrual cycle) Post psychotic depressive Disorder of schizophrenia: a Major Depressive Episode that occurs during the residual phase of schizophrenia.

A Major Depressive Episode superimposed on delusional disorder, Psychotic Disorder Not Otherwise Specified, or the
active phase of schizophrenia.

Situations in which the clinician has concluded that a depressive disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced.

Bipolar Spectrum
Bipolar I : full blown mania Bipolar 1.5 : depression with protracted hypomania Bipolar II : depression with hypomania Bipolar 2.5 : cyclothymic depression Bipolar III : hypomanic episodes which occur only after taking antidepressant medications. Bipolar IV :disorder of ultra-rapid cycling of mood between hypomania or mania and depression.

Bipolar Disorder
Two Main Distinctions

Bipolar I Disorder:

Technically, this should mean Mania/Mixed + Depression Actually, this means Mania/Mixed Depression

Bipolar II Disorder:

Hypomania + Depression (No mania ever)

Bipolar I Disorder
One or more manic episode

OR

Depressed and manic episodes

Manic or Mixed Episode

OR

Major Depressive Episode

Manic or Mixed Episode

Bipolar II Disorder
One or more hypomanic episode

OR

Depressed and hypomanic episodes

OR
Hypomanic Episode

Major Depressive Episode

Hypomanic Episode

Manic Episode (building block)

A. B.

Distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week During the mood disturbance, 3 or more of the following symptoms have persisted (4 or more if the mood is only irritable)
1.
2. 3. 4.

5.
6. 7.

Inflated self-esteem or grandiosity Decreased need for sleep More talkative than usual, or pressure to keep talking Racing thoughts (flight of ideas) Distractibility Increase in goal-directed activity Excessive involvement in pleasurable activities that have the potential for negative consequences

Manic Episode (building block)

C. The symptoms do not meet criteria for a Mixed Episode D. The symptoms cause significant impairment in functioning or necessitate hospitalization to prevent harm to self or others

E. Not due to a GMC or substance

Mixed Episode (building block)

A. The criteria are met for both a Manic Episode and a Major Depressive Episode (except duration) nearly every day during at least a 1-week period

B. The symptoms cause significant distress or impairment in functioning C. Not due to a GMC or substance

Hypomanic Episode (building block)

A. B.

Distinct period of persistently elevated, expansive, or irritable mood lasting at least 4 days During the mood disturbance, 3 (or more) of the following symptoms have been present (4 or more if mood is only irritable)
1.
2. 3. 4.

5.
6. 7.

Inflated self-esteem or grandiosity Decreased need for sleep More talkative than usual, or pressure to keep talking Racing thoughts (flight of ideas) Distractibility Increase in goal-directed activity Excessive involvement in pleasurable activities that have the potential for negative consequences

Hypomanic Episode (building block)

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic D. The mood disturbance and change in functioning are observable to others

E. The episode is not severe enough to cause marked distress or impairment in functioning and does not require hospitalization
F. Not due to a GMC or substance

Clinical Picture of Mania

Elevated, Expansive, Irritable mood Increase energy ( hyperactivity, reduced need for sleep, pressured speech ) Increaese self esteem ( grandiosity , disinhibition ) Decreased attention and concentration Psychotic symtoms Marked disruption in work and social life

Mental State Examnination

General description: talkative , irritable, hyperactive, disinhibited , hallucinatory behavior . Mood and affect: Elevated, Expansive, Irritable mood . Speech: pressure of talk, cannot be intruptted , intrusive, flight of ideas , loss of associations, totally incoherent . Perception: Hallucinations , delusions. Orientation and memory: intact . Impaired judgement and insight .

Mood Episodes
Mania Hypomania Mixed Episode

Normal Mood

Depression

Unipolar vs. Bipolar Disorder

Elevated Mood Bipolar Depressed Mood Elevated Mood Unipolar Depressed Mood

Cyclothymia
A.

B.

C.

D.
E.

For at least two years (one year for children and adolescents) presence of numerous hypomanic episodes and numerous periods with depressed mood or loss of interest or pleasure that did not meet criterion A (5 symptoms) of Major Depression During a two-year period (1 year in children and teens) of disturbance, never without hypomanic or depressive symptoms for more than tow months at a time No evidence of MDD or Manic episode during the first two years of disturbance No psychotic disorder No organic cause

Rapid cycling
Qualifier for either Bipolar I or Bipolar II disorder Four or more mood episodes (any type) within any 1 year period Occurs in 10%-20% of patients with bipolar disorder 70%-90% of rapid-cyclers are women Can be very difficult to treat

Mood Disorders: Severity

Mild Moderate Severe without Psychotic features Severe with Psychotic features

Differential Diagnosis for Mood Disorders

Other mood and anxiety disorders Mood disorder due to a general medical condition Substance-induced mood disorder Bereavement Adjustment disorder with depressed mood Psychotic disorders Premenstrual dysphoric disorder (??) Depression NOS and Mood Disorder NOS

Medical conditions

Thyroid abnormalities Cortisol abnormalities Parkinsons disease Multiple sclerosis Epilepsy Brain tumor Cancer (e.g., pancreatic) Dementia Traumatic brain injury Autoimmune disorders

Stroke Huntingtons disease Chronic infections Certain medications:

Steroids Interferon Beta-blockers Isotretinoin (Accutane) Oral contraceptives Stimulant and appetite supressant Antineoplastic Sedative ,hypnotic, antibacterial,antifungal

Pharmacological Causes of Mania

Amphetamines Baclofen Bromocriptine Cocaine Captopril Corticosteroids Opiates and opioids Levodopa Isoniazide Hydralazine

Diagnostic criteria for SubstanceInduced Mood Disorder

A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following: (1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities (2) elevated, expansive, or irritable mood B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2): (1) the symptoms in Criterion A developed during, or within 1 month of, Substance Intoxication or Withdrawal (2) medication use is etiologically related to the disturbance C. The disturbance is not better accounted for by a Mood Disorder that is not substance induced. Evidence that the symptoms are better accounted for by a Mood Disorder that is not substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance-induced Mood Disorder (e.g., a history of recurrent Major Depressive Episodes). D. The disturbance does not occur exclusively during the course of a Delirium. E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Substance-induced mood disorder

Alcohol: depression Cocaine: hypomania, mania Amphetamines: hypomania, mania

PCP, ketamine: hypomania, mania Heroin: depression? Marijuana: depression?

Mood symptoms with intoxication or withdrawal May take weeks-months to normalize mood Substance use highly comorbid in mood disorders (bipolar I > bipolar II > MDD)

Mood Disorder Due to a General Medical Condition

A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following: (1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities (2) elevated, expansive, or irritable mood B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. C. The disturbance is not better accounted for by another mental disorder (e.g.,Adjustment Disorder With Depressed Mood in response to the stress of having a general medical condition). D. The disturbance does not occur exclusively during the course of a delirium. E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify type: With Depressive Features: if the predominant mood is depressed but the full criteria are not met for a Major Depressive Episode With Major Depressive-Like Episode: if the full criteria are met (except Criterion D) for a Major Depressive Episode With Manic Features: if the predominant mood is elevated, euphoric, or irritable With Mixed Features: if the symptoms of both mania and depression are present but neither predominates Coding note: Include the name of the general medical condition on Axis I, e.g., 293.83 Mood Disorder Due to Hypothyroidism, With Depressive Features; also code the general medical condition on Axis III. Coding note: If depressive symptoms occur as part of a preexistingDementia, indicate the depressive symptoms by coding the appropriate subtype of the dementia if one is available, e.g., 290.21 Dementia of the Alzheimer's Type, With Late Onset, With Depressed Mood.

Course of Mood Disorder

Untreated depreesive episode lasts for 9 months, most treated episodes last for 3 months Untreated manic episodes last for 3 months Of persons have manic episodes, 90% are likely to have another attack 5-15% can be classified as rapid cyclers. Mean age for switch of the depressive phase to manic phase is 32.

Prognosis
Patients with bipolar 2 have a poorer prognosis than those with major depressive disorder

Good prognostic signs

Bad prognostic signs

Mild episodes Absence of psychotic symtoms Short hospital stay Solid friendship during adolescence Stable family functioning Sounds social functioning Absence of comorbid psychiatric disorder

Dysthymic disorders Abuse of alcohol or other substance Anxiety disorder symptoms History of more than one depressive episodes

Suicide

Risk Factors:

Best predictor = Prior attempt Living alone, especially if divorced/separated Retired/unemployed Elderly Loss of a loved one Chronic illness Financial troubles Feelings of hopelessness Impulsivity Sexual identity difficulties

Suicide

Suicide and Psychopathology

Bipolar Disorder > Major Depression

Melancholic Depression Substance abuse/dependence Insomnia Delusions

Suicide

Who attempts? Who completes?

Women: 3-4 times more likely to attempt suicide

Men: 3-4 times more likely to complete suicide Ages 18-24: Peak age for attempting suicide Ages 65+: Peak age for completing suicide Method Intent

Suicide

Common Warning Signs

Symptoms of depression
Talking about death, disappearing, ending it all, etc., even just in passing Writing letters, saying last goodbyes

Getting rid of personal effects, making a will

Arranging for the care of pets, plants, etc.

Extravagant spending

Suicide

Prevention

Help the person regain ability to cope with immediate stressors Maintaining supportive contact with the person Help the person realize that their distress is impairing their judgment Help the person realize that the distress is not endless Broad based programs focused on high-risk groups Crisis hotlines Call 911/ER