MOOD DISORDERS

EMOTIONS

AFFECT:Short-lived, emotional Response to an event

MOOD:Sustained and pervasive

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

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

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

CLASSIFICATION

Manic Episode Depressive Episode Bipolar Affective Disorder Recurrent Depressive Disorder Persistent Mood Disorder (cyclothymia

and dysthymia)

Mania: Clinical Features Core features

Elevated/ irritable mood Increased speechDecreased need for sleep Increased psychomotor activity

Psychotic featuresDelusionsHallucinations

Others 7

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

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2. Increased speecho Volubilityo Accelerationo Pressured speech- difficult to interrupto Flight of ideas- shift from topic to topic with

cueso Prolixity- ordered flight of ideas

3. Increased psychomotor activityo Over activity/ restlessnesso Excitement o Stupor

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4. Psychotic symptoms

Delusions: grandiose, love, persecutory

Hallucinations

5. Other symptoms

o Over religiosityo Over spending/ expansive ideaso Over familiarity/ disinhibitiono Appearanceo Appetite may be increased, but decreased

food intake due to over-activityo Decreased need for sleep

Psychiatric Interview

http://www.youtube.com/watch?v=zA-fqvC02oM&feature=relmfu

DEPRESSIVE EPISODE: Clinical Features

1. 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

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

3. Anergia:

Easy fatigability Increased effort to perform simple tasks

4. Depressive ideation: Hopelessness Helplessness Worthlessness Feelings of guilt Death wishes Suicidal ideas

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

6. Biological functions/ somatic syndrome: Insomnia Loss of appetite and weight Loss of sexual drive Early morning awakening (atleast 2 hrs) Diurnal variation

7. Psychotic Symptoms:

Delusions of guilt, nihilism, poverty

Hallucinations

Other symptoms

Difficulty in concentration Forgetfulness Low self-esteem Decreased self-confidence

Psychiatric Interview

http://www.youtube.com/watch?v=4YhpWZCdiZc

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

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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

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

Next Class

Course and Prognosis Epidemiology Treatment Differential Diagnosis Co-morbidities Other syndromes of depression and mania

Psychiatric Interviews

http://www.youtube.com/watch?v=4YhpWZCdiZc

http://www.youtube.com/watch?v=zA-fqvC02oM&feature=relmfu

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

Epidemiology PrevalenceAnnual incidence is <1%, milder forms often missed

Sex ratioEqual prevalence among men and womenManic episodes more common in men and depressive episodes more common in women

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Age of onsetOnset earlier than depressive episodeRanges from 5-50yrs; mean age 30yrs

Marital statusMore common in divorced and single persons

Socioeconomic statusHigher than average incidence among upper socioeconomic status

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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

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Diagnosis- ICD 10 criteria Hypomania- lesser degree of mania

o Persistent mild elevation of mood- euphoriao Marked feelings of well being and efficiencyo Increased energy and activityo Decreased need for sleepo Increased sociability and talkativenesso Not leading to severe disruption of work or

social rejectiono Present for several days on end (4 days)

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Mania without psychotic symptomso Last for at least 1wko Severe enough to disrupt ordinary work and

social activitieso Elated moodo Increased energy with over activityo Pressured speecho Decreased need for sleepo Marked distractibilityo Disinhibited, overspendingo Expansive ideas

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Mania with psychotic symptomso More severe formo Delusions- grandiose and/or persecutoryo Perceptual abnormalitieso Severe and sustained physical activity,

excitemento Flight of ideas, incoherenceo Impaired personal care

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Etiology Biological theories

1.Genetic factors

2.Neurotransmitter theories- inconsistento Dopamine- raised in mania and vice versa

3.Neuroendocrine theorieso CSF somatostatin- raised in mania and vice

versa

4.Neuroimaging and anatomyo Regions involved in regulation of normal

emotions- PFC, antr cingulate, hippocampus, amygdala

o Ventricular enlargement 34

Contd-

Psychosocial theories

1.Life events and stresso Play a formative role in depression;

precipitating in maniao More often precede first rather than the

subsequent episodes

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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

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Treatment Pharmacological- Acute- Mood stabilizers

Antipsychotics

Benzodiazapines

Antidepressants

ECTs

Prophylaxis- Mood stabilizers Non pharmacological- Psycho education

CBT

Interpersonal therapy

Family and group therapy

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Contd-Mood stabilizersLithium- exact mechanism of action unknown

Indications- acute mania

prophylaxis of unipolar and

bipolar disorder

adjuvant to antidepressant

impulsive/ aggressive behavior

Blood level- 0.8- 1.2meq/L- therapeutic

0.6- 1.0meq/L- prophylactic

>2meq/L- toxic 38

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

Teratogenic- Ebsteins anomaly

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Contd- Sodium valproate- acute mania,

prophylaxis

750-2500mg/day

rapid onset of response

Carbamazepine Oxcarbazepine Lamotrigine- depression, prophylaxis; skin Topiramate

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Summary Clinical features- 4 core features

psychotic features

others

Management- pharmacological- acute

prophylaxis

non-pharmacological

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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

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Etiology Biological theories

1.Genetic factorso 3 fold increase in biological relativeo Increased concordance rate for monozygotic

twinso Chromosome 18, 21, 22

2.Neurotransmitter theories- inconsistento Serotonin and norepinephrine- depressiono Dopamine- reduced in depression and

increased in mania44

Contd-

3. Neuroendocrine theorieso Elevated HPA activity, hypothyroidism-

depressiono CSF somatostatin- raised in mania and vice versa

4. Neuroimaging and anatomyo Regions involved in regulation of normal

emotions- PFC, antr cingulate, hippocampus, amygdala

o Ventricular enlargement

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Contd-Psychosocial theories1.Psychoanalytic theory- mania as defense against underlying depression

2.Life events and stresso Play a formative role in depression;

precipitating in maniao More often precede first rather than the

subsequent episodes

3.Cognitive theory- depression

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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

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