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Mood disorders, Psych II

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  • 1.MOOD DISORDERS HYACINTH C. MANOOD, MD, DPBP

2.

  • Mood is a pervasive and sustained feeling tone that is experienced internally and that influences a person's behavior and perception of the world.
  • Affect is the external expression of mood.

3.

  • Asyndromeconsisting of a cluster of signs and symptomssustainedover weeks to months, which represent amarked departurefrom a persons functioning, andtend to recur , often in periodic or cyclical fashion.

4.

  • MAJOR DEPRESSIVE DISORDERS major depressive episodes only; unipolar depression
  • BIPOLAR 1 DISORDER both manic and depressive episodes or manic episodes alone ( unipolar, pure or euphoric mania)
  • BIPOLAR 2 DISORDER both hypomanic and depressive episodes

5.

  • DYSTHYMIC DISORDER at least 2 years of depressed mood that is not severe enough to fit the diagnosis of MDD
  • CYCLOTHYMIC DISORDER at least 2 years of hypomanic symptoms

6. MOOD DISORDER LIFETIME PREVALENCE Major Depressive Disorder Bipolar I disorder Bipolar II disorder Dysthymia Cyclothymia F = 10 25% M = 5 12% 0.4 1.6% 0.5 6% 0.4 1.0% 7.

  • twofold greater prevalence of major depressive disorder in women than in men.
  • bipolar I disorder has an equal prevalence among men and women.
  • Manic episodes are more common in men, and depressive episodes are more common in women

8.

  • onset of bipolar I disorder is earlier than that of major depressive disorder
  • mean age of 30 forbipolar I disorder ; mean age of onset for major depressive disorder is about 40 years
  • most often in persons without close interpersonal relationships or in those who are divorced or separated

9.

  • higher than average incidence of bipolar I disorder is found among the upper socioeconomic groups;
  • increased risk of having one or more additional comorbid Axis I disorders - alcohol abuse or dependence, panic disorder, obsessive-compulsive disorder (OCD), and social anxiety disorder
  • Comorbid substance use disorders and anxiety disorders worsen the prognosis of the illness and markedly increase the risk of suicide

10. ETIOLOGY

  • Biological Factors
  • A. Biogenic Amines
  • NOREPINEPHRINE
  • - downregulation or decreased sensitivity of -adrenergic receptors;presynaptic 2- receptors
  • SEROTONIN
  • - most commonly associated with depression
  • - depletion of serotonin may precipitate depression

11.

  • 3. DOPAMINE
  • - reduced in depression; increased in mania; D1 receptorsand mesolimbic dopamine pathway.
  • 4. OTHERS
  • -Abnormal levels of choline
  • -Reductions of GABA
  • -G proteins or other second messengers.
  • - Hypercortisolema

12.

  • elevated basal thyroid-stimulating hormone (TSH) level or an increased TSH response to a500-mg infusion of the hypothalamicneuropeptide thyroid-releasing hormone(TRH).
  • -Decreased CSF somatostatin levels have been reported in depression, and increased levels have been observed in mania.

13.

  • B.Alterations of Sleep Neurophysiology
  • (1) an increase in nocturnal awakenings,
  • (2) a reduction in total sleep time,
  • (3) increased phasic rapid eye movement (REM) sleep,
  • (4) increased core body temperature
  • -reduced REM latency

14.

  • KINDLING
  • - the electrophysical process in which repeated subthreshold stimulation of a neuron eventually generates an action potential; kindling in the temporal lobes;
  • NEUROANATOMY:
  • - limbic system, basal ganglia and the hypothalamus

15.

  • C. Genetic
  • -if one parent has a mood disorder, a child will have a risk of between 10 and 25 percent for mood disorder.

16.

  • II. Psychosocial Factors
  • 1. Life Events and Environmental Stress
  • -The life event most often associated with development of depression islosing a parent before age 11 .
  • -The environmental stressor most often associated with the onset of an episode of depression is theloss of a spouse .
  • 2. Personality Factors
  • -Persons with certain personality disorders: OCD, histrionic, and borderline, may be at greater risk for depression

17.

  • 3. Cognitive Theory
  • Aaron Beck postulated acognitive triadof depression that consists of :
  • (1) views about the self : a negative self-precept;
  • (2) about the environment: a tendency to experience the world as hostile and demanding, and
  • (3) about the future : the expectation of suffering and failure.

18.

  • 4. Learned Helplessness
  • - internal causal explanations are thought to produce a loss of self-esteem after adverse external events.
  • -cognitive motivational deficit and emotional deficit

19. DIAGNOSIS

  • DSM IV TR CRITERIA
  • Mood changes
  • Specified period of time
  • Change in activity level, cognitive abilities, and vegetative functions;
  • Impaired interpersonal, social and occupational functioning
  • Exclusion criteria

20. Major Depressive Episode

  • Five (or more) of the following symptoms have been present during the same2-week periodand represent a change from previous functioning; at least one of the symptoms is either (1) or (2):
  • 1. depressed mood most of the day, nearly everyday
  • 2. markedly diminished interest or pleasure
  • 3. significant weight loss when not dieting or weight gain, or a decrease or increase in appetite nearly everyday.
  • 4. insomnia or hypersomnia
  • 5. psychomotor agitation or retardation
  • 6. fatigue or loss of energy
  • 7. feelings of worthlessness or excessiveor inappropriate guilt
  • 8. diminished ability to think or concentrate, or indecisiveness
  • 9. recurrent thoughts of death, recurrent suicidal ideations w/o a specific plan, suicide attempt, or spedific plan for committing suicide
  • .

21.

  • 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 accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation

22. Manic Episode

  • A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lastingat least 1 week(or any duration if hospitalization is necessary).
  • B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree :
  • 1. inflated self-esteem or grandiosity;
  • 2. decreased need for sleep;
  • 3. more talkative than usual or pressure to keep talking ;
  • 4. flight of ideas or a subjective experience that thoughts are racing;

23.

  • 5. distractability
  • 6. increase in goal directed activities or psychomotor agitation;
  • 7. excessive involvement in pleasurable activities that have a high potential for painful consequences.
  • C. The symptoms do not meet the criteria for a mixed episode.
  • D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization
  • E. The symptoms are not due to the direct physiological effects of a substance or a general medical condition.

24. Hypomanic Episode

  • A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughoutat least 4 days , that is clearly different from the usual non-depressed mood.
  • B. During the period of mood disturbance, three (or more) of the manic symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
  • C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.

25.

  • D. The disturbance in mood and the change in functioning are observable by others.
  • E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
  • F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition

26. MIXED EPISODE

  • The criteria are met both for a manic episode and for a major depressive episode nearly every day duringat least a 1-weekperiod.
  • The mood disturbance is sufficiently severe to cause a marked impairment in occupational functioning or in usual social activities and relationships with others, or to necessitate hospitalization;
  • The symptoms are not due to the direct physiological effects of a substance or a general medical condition.

27. MAJORDEPRESSIVEDISORDER

  • If single episode presence of a single MDE;
  • Ifrecurrent 2 or more MDEs.
  • B. The MDE is not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorders NOS;
  • C. There has never been a manic episode, a mixed episode or a hypomanic episode.

28. BIPOLARI DISORDER(single manic episode)

  • Presence of only one manic episode and no past MDE.
  • The manic episode is not better accounted for by schizoaffective disorder, and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorders NOS;

29. BIPOLARI DISORDER (most recent episode ________)

  • Currently or most recently in a ________ episode.
  • There has previously been at least one of the other episodes.
  • The mood episodes in A and B are not better accounted for by schizoaffective disorder, and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorders NOS;

30. BIPOLARII DISORDER

  • Presence or history on one or more MDE.
  • Presence or history of at least one hypomanic episode.
  • There has never been a manic or mixed episode.
  • The mood episodes in A and B are not better accounted for by schizoaffective disorder, and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorders NOS;
  • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

31. DSM-IV-TR Diagnostic Criteria for Dysthymic Disorder

  • Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note : In children and adolescents, mood can be irritable and duration must be at least 1 year.
  • Presence, while depressed, of two (or more) of the following:
    • poor appetite or overeating
    • insomnia or hypersomnia
    • low energy or fatigue
    • low self-esteem
    • poor concentration or difficulty making decisions
    • feelings of hopelessness

32.

  • During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
  • No major depressive episode has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic major depressive disorder, or major depressive disorder, in partial remission

33.

  • There has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria have never been met for cyclothymic disorder.
  • The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as schizophrenia or delusional disorder.
  • 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).
  • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

34. DSM-IV-TR Diagnostic Criteria for Cyclothymic Disorder

  • For at least 2 years, the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.Note:In children and adolescents, the duration must be at least 1 year.
  • During the above 2-year period (1 year in children and adolescents), the person has not been without the symptoms in Criterion A for more than 2 months at a time.

35.

  • No major depressive episode, manic episode, or mixed episode has been present during the first 2 years of the disturbance. Note:After the initial 2 years (1 year in children and adolescents) of cyclothymic disorder, there may be superimposed manic or mixed episodes (in which case both bipolar I disorder and cyclothymic disorder may be diagnosed) or major depressive episodes (in which case both bipolar II disorder and cyclothymic disorder may be diagnosed).
  • The symptoms in Criterion A are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.
  • 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., hyperthyroidism).
  • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

36. TREATMENT 37. GOALS

  • Patients safety must be guaranteed.
  • Complete diagnostic evaluation
  • Treatment plan addressing not just immediate symptoms but patients prospective well-being.

38.

  • Hospitalization
    • The need for diagnostic procedures
    • The risk for suicide or homicide
    • Grossly reduced ability to get food and shelter
    • History of rapidly progressing symptoms
    • Rupture of patients usualsupport system

39.

  • II. Psychosocial Therapy
  • Cognitive Therapy
  • Interpersonal Therapy
  • Behavior Therapy
  • Psychoanatically-oriented Therapy
  • Family Therapy

40.

  • III. Pharmacotherapy
  • Major Depressive Disorder
  • - MAOIs, TCACs, SSRIs, SNRIs
  • B. Bipolar Disorders
  • - Lithium, anticonvulsants, antipsychotics