Mood Disorders

Mood Disorders د.وليد عزيز العميدي
A. Definitions
1. The mood or affective disorders are characterized by a primary disturbance in internal emotional state, causing subjective distress and problems in functioning.
2. Given the patient s current social and occupational situation he or she emotionally feels
a. Somewhat worse than would be expected (dysthymia)
b. Very much worse than would be expected (depression)
c. Somewhat better than would be expected (hypomania)
d. Very much better than would be expected (mania)
3. The mood states of depression and mania are associated with significant negative impact on social and occupational function.
4. The Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, Text Revision (DSM-IV-TR) categories of primary mood disorders are: major depressive disorder, bipolar disorder (I and II), dysthymic disorder, and cyclothymic disorder. Mood disorder owing to a general medical condition and substance-induced mood disorder are secondary mood disorders.
B. Epidemiology
1. There are no differences in the occurrence of mood disorders associated with ethnicity, education, marital status, or income.
2. The lifetime prevalence of mood disorders is
a. Major depressive disorder: 5%–12% for men; 10%–20% for women
b. Bipolar disorder: 1% overall; no sex difference
c. Dysthymic disorder: 6% overall; up to three times more common in women
d. Cyclothymic disorder: less than 1% overall; no sex difference
II. CLASSIFICATION OF MOOD DISORDERS
A. Major depressive disorder
1. Characteristics :Recurrent episodes of depression, each continuing for at least 2 weeks.
2. Masked depression
a. As many as 50% of depressed patients seem unaware of or deny depression and thus are said to have "masked depression."
b. Patients with masked depression often visit primary care doctors complaining of vague physical symptoms.
c. These complaints may be mistaken for hypochondriasis.
d. In contrast to patients with hypochondriasis, depressed patients show other symptoms of depression (e.g., severe weight loss, suicidality) in addition to their physical complaints.
3. Seasonal affective disorder (SAD)
a. SAD is a subtype of major depressive disorder associated with the winter season and short days.
b. SAD is characterized by atypical symptoms of depression (e.g., oversleeping and overeating) and a heavy feeling in
the limbs ("leaden paralysis").
c. Many SAD patients improve in response to full-spectrum light exposure.
4. Suicide risk
a. Patients with major depressive disorder are at increased risk for suicide.
b. Certain demographic, psychosocial, and physical factors affect this risk.
c. The top five risk factors for suicide from highest to lowest risk are
1. serious prior suicide attempt
2. age older than 45 years
3. alcohol dependence
4. history of rage and violent behavior
5. male sex

Symptoms of Depression and Mania
Type of Episode Symptom Likelihood of Occurrence
Depression Depressed mood (has feelings of sadness, hopelessness, helplessness, low self-esteem,and excessive guilt).

Reduced interest or pleasure in most activities (in severe form this is called anhedonia, the inability to respond to pleasurable stimuli)

Reduced energy and motivation

Anxiety (is apprehensive about imagined Dangers)

Sleep problems (wakes frequently at night and too early in the morning)

Cognitive problems (has difficulty with memory and concentration)

Psychomotor retardation (is slowed down) (seen particularly in the elderly) or agitation(is speeded up)

Decreased appetite (has less interest in food and sex; in atypical depression, patients overeat and oversleep)

Diurnal variation in symptoms (feels worse in the morning and better in the evening)

Suicidal ideation (has thoughts of killing oneself)

Suicide (takes one s own life)
Psychotic symptoms (has delusions of destruction and fatal illness)
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+
Mania Elevated mood (has strong feelings of happiness and physical well-being)

Grandiosity and expansiveness (has feelings of self-importance)


Irritability and impulsivity (is easily
bothered and quick to anger)


Disinhibition (shows uncharacteristic lack of modesty in dress or behavior)

Assaultiveness (cannot control aggressive impulses; has problems with the law)


Distractibility (cannot concentrate on relevant stimuli)

Flight of ideas (thoughts move rapidly from one to the other)


Pressured speech (seems compelled to speak quickly)

Impaired judgment (provides unusual responses to hypothetical questions, [e.g., says she would buy a blood bank if she inherited money])

Delusions (that are often grandiose [e.g., of power and influence])
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Approximate percentage of patients in which the sign or symptom is seen: +, less than 25%; ++, 50%; +++, 70%; ++++, more than 90%.

Risk factors for suicide:

Category Factor Increased Risk Decreased Risk
History
Previous suicidal
Behavior (highest risk factor)





Family history
Serious suicide attempt
(about 30% of people who attempt suicide try again and 10% succeed)

Less than 3 months have
passed since the previous attempt

Possibility of rescue was
Remote

Close family member
(especially parent) committed suicide

Having divorced parents
(especially for adolescents)

Being younger than 11 years old at the time of a parent s death Suicidal gesture, but
not a serious
attempt,
was made

More than 3 months
have passed since
the suicidal gesture

Rescue was very
Likely

No family history of
suicide

Intact family


Parents alive through
childhood
Current psychological,
physical, and social
factors Psychiatric symptoms



Depth of depression





Substance use



Physical health






Social relationships



Severe depression
Psychotic symptoms
Hopelessness
Impulsiveness

Initial stages of recovery
from deep depression;
recovering patients may
have enough energy to
commit suicide


Alcohol and drug dependence Current intoxication


Serious medical illness
(e.g., cancer, AIDS)

Perception of serious illness (most patients have visited a physician in the 6 months
prior to suicide

Divorced (particularly men) Widowed
Single, never married
Lives alone Mild depression
No psychotic
symptoms
Some hopefulness
Thinks things out

The depth of severe
depression; patients
??arely have the clarity
of thought or energy
needed to plan and
commit suicide

Little or no substance
use


Good health


No recent visit to
a physician



Married Strong social support
Has children
Lives with others
Demographic factors Age












Sex



Occupation







Race


Religion






Economic conditions
Elderly (persons 65 years of age and older, especially elderly men)

Middle-aged (over 55 years of age in women and 45 years in men)

Adolescents (suicide is the third leading cause of death in those ??5–24 years of age; rates
increase??after neighborhood suicide of a teen or when media depict teenage suicide)


Male sex (men successfully commit suicide three times
more often than women)

Professionals
Physicians (especially women
and psychiatrists)
Dentists
Police officers
Attorneys
Musicians

Unemployed


Caucasian


No religion

Jewish


Protestant




Economic recession or
depression
Children (up to age
15 years)

Young adults (age
25–40 years)









Female sex (although
women attempt suicide
three times more
often than men)

Non-professionals








Employed


Caucasian Non-Caucasian

Religious

Catholic


Muslim



Strong economy
Lethality Plan and means











Method
A plan for suicide (e.g.,
decision to stockpile pills)

A means of committing suicide (e.g., access to a gun)

Sudden appearance of peacefulness in an agitated,depressed patient (he has
reached an internal
decision to kill himself and is now calm)

Shooting oneself
Crashing one s vehicle
Hanging oneself
Jumping from a high place No plan for suicide
No means of suicide










Taking pills or poison
Slashing one s wrists


B. Bipolar disorder
1. In bipolar disorder, there are episodes of both mania and depression (bipolar I disorder) or both hypomania and depression (bipolar II disorder).
2. There is no simple manic disorder because depressive symptoms eventually occur. Therefore, one episode of symptoms of mania alone or hypomania plus one episode of major depression defines bipolar disorder.
3. Psychotic symptoms, such as delusions, can occur in depression (depression with psychotic features) as well as in mania.
a. In some patients (e.g., poor patients with low access to health care), a mood disorder with psychotic symptoms can become severe enough to be misdiagnosed as schizophrenia.
b. In contrast to schizophrenia and schizoaffective disorder, in which patients are chronically impaired, in mood disorders the patient s mood and functioning usually return to normal between episodes.

C. Dysthymic disorder and cyclothymic disorder
1. Dysthymic disorder involves dysthymia continuing over a 2-year period (1 year in children) with no discrete episodes of illness.
2. Cyclothymic disorder involves periods of hypomania and dysthymia occurring over a 2-year period (1 year in children) with no discrete episodes of illness.
3. In contrast to major depressive disorder and bipolar disorder, respectively, dysthymic disorder and cyclothymic disorder are less severe, nonepisodic, chronic, and never associated with psychosis or suicide.

III. ETIOLOGY
A. The biologic etiology of mood disorders includes
1. Altered neurotransmitter activity
2. A genetic component, strongest in bipolar disorder
3. Physical illness and related factors
4. Abnormalities of the limbic-hypothalamic-pituitary-adrenal axis
B. The psychosocial etiology of depression and dysthymia can include
1. Loss of a parent in childhood
2. Loss of a spouse or child in adulthood
3. Loss of health
4. Low self-esteem and negative interpretation of life events
5. "Learned helplessness" (i.e., because attempts to escape bad situations in the past have proven futile, the person now feels helpless)
C. Psychosocial factors are not involved in the etiology of mania or hypomania.


The Genetics of Bipolar Disorder
Group Approximate Occurrence (%)
General population 1%
Person who has one bipolar parent or sibling (or dizygotic twin) 20%
Person who has two bipolar parents 60%
Monozygotic twin of a person with bipolar disorder 75%

Differential Diagnosis of Depression
Medical Conditions Psychiatric and Pharmacologic Conditions
Cancer, particularly pancreatic and
Other gastrointestinal tumors Schizophrenia (particularly after an acute psychotic episode)
Viral illness (e.g., pneumonia, influenza, acquired immune deficiency syndrome [AIDS]) Anxiety disorder
Endocrinologic abnormality (e.g., hypothyroidism, diabetes) Somatoform disorder
Neurologic illness (e.g., Parkinson
disease, Huntington disease, stroke [particularly left frontal]) Eating disorder
Nutritional deficiency (e.g., folic acid, B12) Drug and alcohol abuse (particularly use of sedatives and withdrawal from stimulants)
Renal or cardiopulmonary disease Prescription drug use (e.g., reserpine, steroids,
antihypertensives, antineoplastics)

IV. TREATMENT
A. Overview
1. Depression is successfully treated in most patients.
2. Only about 25% of patients with depression seek and receive treatment.
a. Patients do not seek treatment in part because Americans often believe that mental illness indicates personal failure or weakness.
b. As in other illnesses, women are more likely than men to seek treatment.
3. Untreated episodes of depression and mania are usually self-limiting and last approximately 6–12 months and 3 months respectively. The most effective treatments for the mood disorders are pharmacologic.
B. Pharmacologic treatment
1. Treatment for depression and dysthymia includes antidepressant agents (e.g., heterocyclics, selective serotonin and selective serotonin and norepinephrine reuptake inhibitors [SSRIs and SSNRIs], monoamine oxidase inhibitors [MAOIs],and stimulants).
2. Mood stabilizers
a. Lithium and anticonvulsants such as carbamazepine (Tegretol) and divalproex (Depakote) are used to treat bipolar
disorder.
b. Mood stabilizers in doses similar to those used to treat bipolar disorder are the primary treatment for cyclothymic disorder.
3. Atypical antipsychotics such as olanzapine (Zyprexa) and risperidone (Risperdal).
4. Sedative agents such as lorazepam (Ativan) are used to treat acute manic episodes because they resolve symptoms quickly.
C. Psychological treatment
1. Psychological treatment for depression and dysthymia includes psychoanalytic, interpersonal, family, behavioral, and cognitive therapy .
2. Psychological treatment in conjunction with medication is more effective than either type of treatment alone.
D. Electroconvulsive therapy (ECT) The primary indication for ECT is major depressive disorder. It is used when
1. The symptoms do not respond to antidepressant medications.
2. Antidepressants are too dangerous or have intolerable side effects. Thus, ECT may be particularly useful for elderly patients.
3. Rapid resolution of symptoms is necessary (e.g., the patient is acutely suicidal or psychotic).