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Mood (Affective) Disorders

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Title: Mood (Affective) Disorders


1
Mood (Affective) Disorders
  • Department of Psychiatry
  • 1st Faculty of Medicine
  • Charles University, Prague
  • Head Prof. MUDr. Jirí Raboch, DrSc.

2
Mood (Affective) Disorders
  • Mood disorders are very common, their life
    prevalence is up to 20 , and they have a high
    level of morbidity and mortality as well as an
    immense impact on disabilities worldwide.
  • The fundamental disturbance is a change in mood
    or affect, usually to depression (with or without
    associated anxiety) or to elation. The mood
    change is usually accompanied by a change in the
    overall level of activity.
  • Most of these disorders tend to be recurrent, and
    the onset of individual episodes is often related
    to stressful events or situations.
  • The mood disorders may be subdivided into
    unipolar and bipolar types
  • those that are characterized by depression only
  • those that are characterized by manic episode
    either alone or in combination with depression

3
Classification of Mood Disorders
  • International Classification of Diseases (ICD-10)
    came into use in WHO Member States as from 1994
  • F30 Manic episode
  • F31 Bipolar affective disorder
  • F32 Depressive episode
  • F33 Recurrent depressive disorder
  • F34 Persistent mood (affective) disorders
  • F38 Other mood (affective) disorders
  • F39 Unspecified mood (affective) disorder

4
Test Methods
  • Self-reported scales
  • Young Mania Rating Scale (YMRS)
  • Beck scale (depression)
  • Zung scale (depression)
  • Interview with physician
  • Hamilton scale (HAMD)
  • Montgomery and Asberg scale (MADRS)

5
F32 Depressive Episode
  • Pathological sadness
  • Depressive episode
  • depressed mood
  • loss of interest and enjoyment
  • reduced energy leading to increased fatigability
    and diminished activity
  • marked tiredness after only slight effort
  • reduced concentration and attention
  • reduced self-esteem and self-confidence
  • ideas of guilt and unworthiness
  • bleak and pessimistic views of the future
  • ideas or acts of self-harm or suicide,
  • disturbed sleep and diminished appetite

6
F32 Depressive Episode
  • Clinical presentation shows marked individual
    variations
  • in some cases, anxiety, distress, and motor
    agitation may be more prominent at times than the
    depression
  • the mood change may also be masked (masked
    depression) by added features such as
    irritability, excessive consumption of alcohol,
    histrionic behaviour, and exacerbation of
    pre-existing phobic or obsessional symptoms, or
    by hypochondriacal preoccupations.
  • Depressive episode should last at least 2 weeks
    (typically several months), but shorter periods
    may be reasonable if symptoms are unusually
    severe and of rapid onset.
  • The lifetime prevalence 17 risk of recurrence
    gt50.

7
F32 Depressive Episode
  • The lowered mood varies little from day to day,
    is unresponsive to circumstances and may be
    accompanied by so-called somatic symptoms
  • loss of interest or pleasure in activities that
    are normally enjoyable (anhedonia)
  • lack of emotional reactivity to normally
    pleasurable surroundings and events
  • waking in the morning 2 hours or more before the
    usual time
  • depression worse in the morning
  • objective evidence of definite psychomotor
    retardation or agitation
  • loss of appetite
  • weight loss
  • loss of libido

8
F32 Depressive Episode
  • F32 Depressive episode
  • F32.0 Mild depressive episode
  • F32.1 Moderate depressive episode
  • F32.2 Severe depressive episode without psychotic
    symptoms
  • F32.3 Severe depressive episode with psychotic
    symptoms
  • F32.8 Other depressive episodes
  • F32.9 Depressive episode, unspecified

9
F32.0 Mild Depressive Episode
  • Two or three of the above symptoms are usually
    present.
  • For mild depressive episode are typical depressed
    mood, anhedonia and increased fatigability. The
    afflicted person is usually distressed by the
    symptoms and has some difficulty in continuing
    with ordinary work and social activities, but
    will probably not cease to function completely.

10
F32.1 Moderate Depressive Episode
  • An individual with moderate depressive episode
    suffers from more symptoms (four or more of the
    above symptoms are usually present) of greater
    severity and will usually have considerable
    difficulty in continuing with social, work or
    domestic activities.

11
F32.2 Severe Depressive Episode without Psychotic
Symptoms
  • In a severe depressive episode, the sufferer
    usually shows considerable distress or agitation.
    Loss of self-esteem or feelings of uselessness or
    guilt are likely to be prominent, and suicide is
    a distinct danger in particularly severe cases.
    a number of "somatic" symptoms are usually
    present.
  • Agitated depression
  • Major depression
  • Vital depression

12
F32.3 Severe Depressive Episode with Psychotic
Symptoms
  • Psychotic symptoms may be present, such as
  • delusions (ideas of sin, poverty or imminent
    disasters)
  • hallucinations (defamatory or accusatory voices
    or of rotting filth or decomposing flesh)
  • depressive stupor
  • Severe ordinary social activities are impossible
  • When the psychotic symptoms are consistent with
    the patients mood, they are referred to as mood
    congruent, when they are inconsistent, they are
    referred as mood incongruent.
  • Single episodes of
  • major depression with psychotic symptoms
  • psychogenic depressive psychosis
  • psychotic depression
  • reactive depressive psychosis

13
F33 Recurrent Depressive Disorder
  • Recurrent depressive disorder is characterized by
    repeated episodes of depression without any
    history of independent episodes of mood elevation
    and overactivity.
  • Recovery is usually complete between episodes,
    but a substantial part of patients will have a
    recurrence and about 30 may develop a persistent
    depression.
  • The lifetime prevalence - about 1020
    womenmen 21.
  • The risk of suicide (approximately 1015.
  • Seasonal affective disorder - onset of mood
    symptoms is connected with changes of seasons,
    with depression typically occurring during the
    winter months and remissions or changes from
    depression to mania occurring during the spring.

14
F33 Recurrent Depressive Disorder
Kupfer 1991
15
F33 Recurrent Depressive Disorder
  • F33 Recurrent depressive disorder
  • F33.0 Recurrent depressive disorder, current
    episode mild
  • F33.1 Recurrent depressive disorder, current
    episode moderate
  • F33.2 Recurrent depressive disorder, current
    episode severe without psychotic symptoms
  • F33.3 Recurrent depressive disorder, current
    episode severe with psychotic symptoms
  • F33.4 Recurrent depressive disorder, currently in
    remission
  • F33.8 Other recurrent depressive disorders
  • F33.9 Recurrent depressive disorder, unspecified

16
F30 Manic Episode
  • F30 Manic episode
  • F30.0 Hypomania
  • F30.1 Mania without psychotic symptoms
  • F30.2 Mania with psychotic symptoms
  • F30.8 Other manic episodes
  • F30.9 Manic episode, unspecified

17
F30.0 Hypomania
  • Hypomania is characterized by
  • persistent mild elevation of mood for at least
    several days
  • increased energy and activity
  • usually marked feelings of well-being and both
    physical and mental efficiency
  • Increased sociability, talkativeness,
    overfamiliarity, increased sexual energy, and a
    decreased need for sleep are often present but
    not to the extent that they lead to severe
    disruption of work or result in social rejection.
    There are no hallucinations or delusions

18
F30.1 Mania without Psychotic Symptoms
  • Mania without psychotic symptoms
  • last for at least 1 weak
  • mood is elevated out of keeping with individuals
    circumstances and may vary from carefree
    joviality to almost uncontrollable excitement
  • elation is accompanied by increased energy,
    resulting in overactivity, pressure of speech,
    and a decreased need for sleep
  • normal social inhibition are lost, attention
    cannot be sustained, and there is often marked
    distractibility
  • self-esteem is inflated, and grandiose or
    over-optimistic ideas are freely expressed
  • perceptual disorders may occur
  • the individual may embark on extravagant and
    impractical schemes, spend money recklessly, or
    become aggressive, amorous, or factious in
    inappropriate circumstances.

19
F30.2 Mania with Psychotic Symptoms
  • Mania with psychotic symptoms represents a more
    severe form of mania
  • inflated self-esteem and grandiose ideas may
    develop into delusions, and irritability and
    suspiciousness into delusions of persecution
  • in severe cases, grandiose or religious delusions
    of identity or role may be prominent, and flight
    of ideas and pressure of speech may result in the
    individual becoming incomprehensible
  • sustained physical activity and excitement may
    result in aggression or violence, and neglect of
    eating, drinking, and personal hygiene may result
    in dangerous states of dehydration and self
    neglect
  • Mania with
  • mood-congruent psychotic symptoms
  • mood-incongruent psychotic symptoms
  • Manic stupor

20
F31 Bipolar Affective Disorder
  • Bipolar affective disorder is characterized by
    repeated, at least two episodes in which the
    patients mood and activity levels are
    significantly disturbed (manic or depressive
    syndromes, patients who suffer only from repeated
    episodes of mania are comparatively rare).
  • The first episode may occur at any age from
    childhood to old age.
  • The frequency of episodes and the pattern of
    remissions and relapses are both very variable.
  • The lifetime prevalence is between 0,5 an 1 .
    Suicidality about 19. Comorbidity with alcohol
    and drug abuse
  • The rapid-cycling specifier identifies those
    patients who have had at least four episodes of a
    major depressive, manic, or mixed episode during
    the past 12 months.

21
F31 Bipolar Affective Disorder
  • F31 Bipolar affective disorder
  • F31.0 Bipolar affective disorder, current episode
    hypomanic
  • F31.1 Bipolar affective disorder, current episode
    manic without psychotic symptoms
  • F31.2 Bipolar affective disorder, current episode
    manic with psychotic symptoms
  • F31.3 Bipolar affective disorder, current episode
    mild or moderate depression
  • F31.4 Bipolar affective disorder, current episode
    severe depression without psychotic symptoms
  • F31.5 Bipolar affective disorder, current episode
    severe depression with psychotic symptoms
  • F31.6 Bipolar affective disorder, current episode
    mixed
  • F31.7 Bipolar affective disorder, currently in
    remission
  • F31.8 Other bipolar affective disorders
  • F31.9 Bipolar affective disorder, unspecified

22
F34 Persistent Mood (Affective) Disorders
  • Persistent mood disorders are persistent and
    usually fluctuating disorders of mood in which
    individual episodes are not sufficiently severe
    to warrant being described as hypomanic or even
    mild depressive episodes.
  • Lasting more than 2 years
  • F34 Persistent mood (affective) disorders
  • F34.0 Cyclothymia
  • F34.1 Dysthymia
  • F34.8 Other persistent mood (affective) disorders
  • F34.9 Persistent mood (affective) disorder,
    unspecified

23
F34.0 Cyclothymia
  • For cyclothymia persistent instability of mood,
    involving periods of mild depression and mild
    elation is typical.
  • This instability usually develops early in adult
    life and pursues a chronic course, although the
    mood may be normal and stable for months at a
    time.
  • The mood swings are usually perceived by the
    individual as being unrelated to life events.

24
F34.1 Dysthymia
  • Dysthymia represents a chronic, milder form of
    depression which does not fulfill the criteria
    for recurrent depressive disorder especially in
    terms of severity.
  • Sufferers usually have periods of days or weeks
    when they describe themselves as well, but most
    of the time they feel tired and depressed.
  • It usually begins in adult life and lasts for at
    least several years, sometimes indefinitely.
  • The lifetime prevalence is approximately 3, and
    it is more common in women.

25
F34.1 Dysthymie
  • dysthymie mírná chronická deprese
  • epidemiologie celoživotní prevalence kolem 3
  • etiopatogeneze faktory genetické i vnejší
  • lécba jako u depresivní poruchy
    kognitivne-bahaviorální psychoterapie,
    antidepresiva

26
Treatment of Depression
  • Various antidepressants altering levels of
    central neurotransmitters are available to treat
    depression.
  • Their overall effectiveness 65-70
  • Mild to moderate depressive episode SSRIs.
  • Severe depression antidepressants with broader
    spectrum of effects, like SNRI or TCA.
  • Patients with insomnia or anorexia may do better
    with more sedating medication (mirtazapine,
    trazodon)
  • Patients with lethargy, hypersomnia, weight gain
    and lower levels of tension and anxiety may
    prefer the less sedating medications such as
    bupropion, reboxetin or stimulating SSRIs.
  • IMAOs or RIMA should be tried in refractory
    patients or patients with atypical depression.

27
Treatment of Depression
  • Drug trials should last 4 to 8 weeks.
  • No response within 4 weeks of treatment - the
    dose should be increased or the patient should be
    switched to another drug.
  • In partial responders - augmentation strategy
    coadministration of lithium carbonate or
    trijodthyronine.
  • Psychotic patient - adding on neuroleptics.
  • Anxious or agitated patients (also to improve the
    sleep quality) - benzodiazepine coadministration
    for a short period of time.
  • Lithium prophylaxis is an option to
    antidepressants.
  • Supportive psychotherapy.

28
Treatment of Depression
  • First episode of depression - the drug should be
    continued for another 16-20 weeks after the
    patient is thought to be well (continuation
    treatment to prevent recurrence).
  • The medication should be tapered gradually
    because many patients experience some mild
    withdrawal effects.
  • Patients with recurrent depression need long-term
    maintenance therapy to prevent relapses.
  • Electroconvulsive therapy (ECT) is the treatment
    of choice for some patients with very severe
    depression, with high potential for suicide or
    other selfdestroying behaviour and for pregnant
    women.
  • Other biological methods
  • phototherapy (seasonal affective disorder)
  • sleep deprivation
  • repetitive transcranial magnetic stimulation
    (rTMS).

29
Treatment of Mania
  • Mood stabilizers
  • lithium (0.61.2 mEq/L)
  • carbamazepine (612 mg/L)
  • valproate (50125 mg/L)
  • Anticonvulsants
  • gabapentine
  • topiramate
  • lamotrigine
  • Agitated or psychotic patient coadministartion
    of
  • antipsychotics of second generation (olanzapine,
    risperidone)
  • benzodiazepines (lorazepam, clonazepam)
  • ECT
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