Mood Disorders

1
Mood Disorders

• Major Depression
• And
• Bipolar Disorder

2
Mood Disorders

• A wide range of behaviors are seen in mood
  disorders. The three main types of mood disorder
  are depressive disorders, bipolar disorders, and
  other mood disorders which are substance-induced
  or due to general medical conditions.
• Facts about Mood Disorders Depressive disorder is
  relatively common. Bipolar disorders are much
  less common than depressive disorder. The overall
  rates of both depressive and bipolar disorders,
  but not their typical symptoms, seem to be
  affected by a variety of cultural, economic, and
  environmental factors.

3
Types of mood disorder

• Depressive Disorder
• Dysthymic disorder History of depressed mood a
  majority of the time.
• Major depressive disorder One or more major
  depressive episodes.
• Bipolar Disorders
• Bipolar I disorder One or more manic episodes,
  and usually one or more major depressive
  episodes.
• Bipolar II disorder At least one hypomanic
  episode and one or more major depressive episodes
  but no manic episode or cyclothymia.
• Cyclothymic disorder Numerous hypomanic episodes
  and numerous periods of depressive symptoms that
  do not meet criteria for major depressive episode.

4
Depression

• Depression can refer to a symptom or a disorder.
  The symptom of depressed mood does not
  necessarily mean a person has a depressive
  disorder. Although some symptoms of depression
  occur frequently in people who have the blues
  but are nor clinically depressed, those who do
  not meet DSM IV criteria experience more symptoms
  and symptoms are more sever. Depressive disorders
  are sometime referred to as unipolar disorder to
  differentiate these types of depression from that
  found in bipolar disorder. There are several
  categories of depressive disorder. Patients often
  describe the symptom of depression as one
  agonizing emotional pain and sometimes complain
  about unable to cry, a symptom that resolves as
  they improve. About two thirds of all depressed
  patients contemplate suicide, and 10 to 15
  percent commit suicide.

5
Structures of mood disorders

• A.   Unipolar disorder refers to the experience
  of either depression or mania, and most
  individuals with this condition suffer from
  unipolar depression. Bipolar disorder refers to
  alternations between depression and mania.
  Feeling depression and manic at the same time is
  referred to as a dysphoric manic or mixed
  episode.
• B.  An important feature of major depressive
  episodes is that they are time limited, lasting 2
  weeks to 9 months if left untreated.
•  C.  Almost all major depressive episodes remit
  without treatment. Manic episodes remit without
  treatment after six months. Thus, it is
  important to determine the course or temporal
  patterning of the depressive and manic episodes.
  Different patterns appear in the DSM-IV-TR under
  the heading course modifiers for mood disorders.
  
• D. Course modifiers characterize the past mood
  state and are helpful to predict the future
  course of the disorder. Understanding the course
  is related to predicting future occurrences of
  mood changes and in helping to prevent them.

6
Dysthymic Disorder

•      Dysthymic disorder shares many of the
  symptoms of major depressive, but unlike major
  depression, the symptoms in dysthymia tend to be
  milder and remain relatively unchanged over long
  periods of time, as much as 20 or 30 years.
  Dysthymic disorder is defined by persistently
  depressed mood that continues for at least 2
  years. During this time, the person cannot be
  symptom free for more than 2 months at a time.
  Many eventually experience a major depressive
  episode at some point.
• a.        The mean age of onset for dysthymia is
  typically in the early 20s (i.e., late onset).
  The onset of dysthymia before age 21 (i.e., early
  onset) is associated with (a) greater chronicity,
  (b) relatively poor prognosis (i.e., response to
  treatment), and (c) stronger likelihood of the
  disorder running in the family.
• b.       The median duration of dysthymic
  disorder is approximately 5 years in adults and 4
  years in children.
• c.        Patients suffering from dysthymia have
  a higher likelihood of attempting suicide than
  those suffering from major depressive disorder.

7
DSM-IV-TR Diagnostic Criteria for Dysthymic
Disorder

• A.depressed mood for mood for most of the day,
  for more days than not, as indicated either by
  subjective account or observation by other, for
  at least 2 years. Note In adolescents, mood can
  be irritable and duration must be at least 1
  year.
• B. Presence, while depressed, of two (or more0 of
  the following
• Poor appetite or over eating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness
• C. During the 2-year period (1 yr. For children
  or adolescents) of the disturbance, the person
  has never been without symptoms in criteria A and
  criteria B for more than 2 months at a time.

8
Cont.DSM-IV-TR Diagnostic Criteria for Dysthymic
d/o

• D. No major depressive episode has been present
  during the first 2 years of the disturbance (1
  year for children and adolescent_ I.e. the
  disturbance is not better accounted for by
  chronic major depressive disorder, in partial
  remission. Note there may have been previous
  major depressive episode provided there was full
  remission (no significant signs or symptoms for
  2 months) before development of the dysthymic
  disorder.
• E. There has never been a manic episode, a mixed
  episode, or a hypomanic episode, and criteria
  have never been met for cyclothymic disorder.
• F. The disturbance does not occur exclusively
  during the course of a chronic psychotic
  disorder, such as schizophrenia or delusional
  disorder.

9
Cont. Diagnostic criteria for Dysthymic Disorder

• G. The symptoms are not due to the direct
  physiological effects of a substance (e.g. drug
  of abuse, a medication) or general medical
  condition (e.g. hypothyroidism)
• H. The symptoms cause clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.
• Specify if
• Early Onset if onset is before age 21 years
• Late onset if onset is age 21 years or older
• Specify (for most recent 2 years of dysthymic
  disorder)
• With atypical features

10
Cont. Depression

• Almost all depressed patients (97 percent0
  complain about reduced energy they have
  difficulty finishing tasks, are impaired at
  school and work, and have less motivation to
  undertake new projects. About 80 percent of
  patients complain of trouble sleeping,
  especially, especially early awakening (I.e.
  terminal insomnia) and multiple awakenings at
  night, during which they ruminate about their
  problems. Many patients have decrease appetite
  and weight gain and sleep longer than usual.
  These pt.s are classified in DSM-IV-TR as having
  atypical features. Other vegetative symptoms
  include abnormal menses and decrease interest and
  performance in sexual activities.

11
Depressed Mood

• In every language, we often use the term
  depression to refer to normal feelings
  experiences after significant loss, such as the
  breakup of a relationship or the failure to
  attain a significant goal. Theses feelings are
  not classified as a depressive disorder by
  DSM-VI. Symptoms of grief over the death of a
  loved one also are not classified as a depression
  unless they continue for an unusually long period.

12
Vulnerability factors for depression

• Genetic makeup, or heredity, is an important risk
  factor for both major depression and bipolar
  disorder. Age is also a risk factor. Women are
  particularly a risk during young adulthood, while
  for men the risk is highest in early middle age.
  Gender is also a related risk. Twice as many
  women as men in the general population report a
  depressive disorder. Other risk factor are
  experiencing negative life events and lack of
  social support, particularly from close
  relationships. This support may be especially
  valuable if stressful life events have recently
  occurred.

13
Major depressive disorder

• A major depressive episode is marked by either
  depressed mood or a loss of interest or pleasure
  in almost all activities and at least four
  additional symptoms from the following group
  marked weight loss or gain when not dieting
  constant sleeping problems agitated or greatly
  slowed-down behavior fatigue inability to think
  clearly feelings of worthlessness, and frequent
  thoughts about death or suicide. These symptoms
  must last at least 2 weeks and represent a change
  from the persons usual functioning.

14
Diagnostic criteria for 296.2x Major Depressive
Disorder, Single Episode

• presence of a single Major Depressive Episode
• The major Depressive Episode is not better
  accounted for by Schizaoaffective Disorder and is
  not superimposed on schizoaffective,
  Schizophreniform Disorder, Delusional Disorder,
  or Psychotic Disorder Not Otherwise Specified.
• There has never been a manic episode, a mixed
  episode, or a hypomanic episode. Note this
  exclusion does not apply if all of the
  manic-like, or hypomanic-like episode are
  substance or treatment induced or are due to the
  direct physiological effects of a general medical
  condition.

15
Cont. diagnostic criteria for major depressive
disorder, single episode

• If the full criteria are currently met for a
  Major Depressive Episode, specify its current
  clinical status and/or features
• Mild, Moderate, Severe Without Psychotic
  Features/Severe With Psychotic Features
• Chronic
• With Catatonic Features
• With Melancholic Features
• With atypical Features
• With Postpartum Features
• If the full criteria are not currently met for a
  Major Depressive Episode, specify the current
  clinical status of the Major Depressive Disorder
• In Partial Remission, In Full Remission
• Chronic
• With Catatonic Features
• With Melancholic Features
• With Atypical Features
• With Postpartum onset

16
Criteria for Major Depressive Episode

• Five (or more) of the following symptoms have
  been present during the same 2-week period and
  represent a change from previous functioning at
  least one of the symptoms is either (1) depressed
  mood or (2) loss of interest or pleasure.
• Note Do not include symptoms that are clearly
  due to a general medical condition, or
  mood-incongruent delusions or hallucinations.
• (1)
• Depressed mood most of the day, nearly every day,
  as indicated by either subjective report (e.g.
  feels sad or empty) or observation made by other
  (e.g. appears tearful) Note in children and
  adolescent can irritable mood.
• (2) Markedly dimishid interest or pleasure in
  all, or almost all, activities most of the day,
  nearly every day (as indicated by either
  subjective account or observation made by
  others).

17
Cont.criteria for major depressive episode

• (3) Significant weight loss when not dieting or
  weight gain (e.g. a change of more than 5 of
  body weight in a month), or decrease or increase
  appetite nearly everyday. Note in children,
  consider failure to make expected weight gains.
• (4) Insomnia or hypersomnia nearly every day.
• (5) Psychomotor agitation or retardation nearly
  every day (observable by others, not merely
  subjective feelings of restlessness or being
  slowed down)
• (6) Fatigue or loss of energy nearly everyday
• (7) Feelings of worthlessness or excessive or
  inappropriate guilt (which may be delusional)
  nearly every day (not merely self-approach or
  guilt about being sick)
• (8) Diminished ability to think or concentrate,
  or indecisiveness, nearly every day (either by
  subjective account or as observed by others)
• ((9) recurrent thoughts of death (not just fear
  of dying), recurrent suicidal ideation without a
  specific plan, or a suicide attempt or a specific
  plan for committing suicide

18
Cont. criteria for depressive episode

• B. The symptoms do not meet criteria for a Mixed
  Episode
• c. The symptoms cause clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.
• D. The symptoms are not due to the direct
  physiological effects of a substance (e.g., a
  drug of Abuse, a medication) or a general medical
  condition (e.g. hypothyroidism).
• E. The symptoms are not better account for by
  bereavement,I.e. after the loss of loved one, the
  symptoms persist for longer than 2 months or are
  characterized by a marked functional impairment,
  morbid preoccupation with worthlessness, suicidal
  ideation, psychotic symptoms, or psychomotor
  retardation.

19
Recurrent Major depressive disorder

• When a person who has experience one major
  depressive episode develops the symptoms again at
  a later time, the diagnosis is changed to
  recurrent major depressive disorder.
• DSM-IV-TR-Diagnostic criteria, p. 376

20
Causes and Treatment of Depression

• Biological factors in Depression- the mechanism
  for depressed or manic behavior may be the
  activity of the neurotransmitter systems. An
  early theory, the monoamine hypothesis focused on
  the neurotransmitters serotonin and the
  catecholamines, but other neurotransmitters
  including GABA and acetylcholine also seem to be
  involved in depression. The study of the effects
  of various antidepressant drugs- including MAO
  inhibitors, tricyclics, and selective serotonin
  reuptake (SSRIs)-has led to hypothesis about the
  role of the neurotransmitters in producing
  behaviors associated with depression. The search
  for for markers of depression has been an
  important research strategy. The markers
  investigated include specific receptor sites in
  the brain, studied by various scanning devices,
  and the role of biological rhythms, especially in
  seasonal affective disorder (SAD).

21
The bipolar disorders

• DSM-IV list four bipolar disorders Bipolar I
  disorder, Bipolar II disorder, cyclothymic
  disorder, and a miscellaneous group.
• Is an illness involving episodes of mania and
  depression.
• Bipolar I will experience episodes of mania and
  usually major depressive episodes as well.
  bipolar d/o has been found to occur with a higher
  frequency of creative people such as artist and
  poets than in the general population. Episodes of
  bipolar d/o tend to recur. The number of
  recurrence is greater in those who have a family
  history that include bipolar disorder.

22
Bipolar disorder I
23
Bipolar disorder

• Bipolar II Disorder is variant of bipolar
  disorder in which there has been no manic episode
  but at least one hypomanic period as well as a
  major depressive episode. A hypomanic episode
  refers to a period of manic behavior that is not
  extreme enough to greatly impair function. People
  who experience a hypomanic episode may not see it
  as pathological, although those around them may
  be concerned about the erratic behavior they see.
  For the person affected, the feelings of elation
  and creativity and the driving energy
  characteristic of the hypomanic state can be
  positive forces.
• DSM-IV-TR Diagnostic criteria, p.397

24
Manic/hypomanic mixed episodes

• A manic episode is a distinct period of
  abnormality and persistently elevated, expansive,
  o irritable mood lasting for at least 1 week, or
  less if a patient must be hospitalized. A
  hypomanic episode lasts at least 4 days and is
  similar to a manic episode except that is not
  severe enough to cause impairment in social or
  occupational functioning, and no psychotic
  features are present. Both mania and hypomania
  are associated with inflated self-esteem,
  decrease need for sleep, distractibility, great
  physical and mental activity, and over
  involvement in pleasurable behavior