Mood disorders - كلية الطب•Individuals with major mood disorders are at an increased risk...

Mood disorders

Dr. Layali Abbasi Psychiatrist

Balqa University 5th year/Faculty of Medicine

2019-2010

• Mood: pervasive and sustained emotion or feeling tone that influence a person’s behavior and colors his or her perception of being in the world.

• A variety of adjectives are used to describe mood: depressed, sad, empty, melancholic, distressed, irritable, disconsolate, elated, euphoric, manic, gleeful, and many others, all descriptive in nature.

Epidemiology Prevalence

• Mood disorders are common.

• In the most recent surveys, major depressive disorder has the highest lifetime prevalence ( almost 17 % ) of any psychiatric disorder.

• The lifetime prevalence rate for major depression is 5 to 17 percent.

• The lifetime prevalence rate for bipolar I disorder is around 0-2.4% .

Epidemiology Sex

• There is twofold greater prevalence of major depressive disorder in women than in men. The reasons for the difference are hypothesized to involve hormonal differences, the effects of childbirth, differing psychosocial stressors for women and for men, and behavioral models of learned helplessness.

• 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.

• Women also have a higher rate of being rapid cyclers.

Epidemiology

Age • The onset of bipolar I disorder is earlier than that

of major depressive disorder.

• The age of onset for bipolar I disorder ranges from childhood (as early as age 5 or 6 years) to 50 years or even older in rare cases, with a mean age of 30 years.

• The mean age of onset for major depressive disorder is about 40 years, with 50 percent of all patients having an onset between the ages of 20 and 50 years.

Epidemiology Age

• Major depressive disorder can also begin in childhood or in old age. Recent epidemiological data suggest that the incidence of major depressive disorder may be increasing among people younger than 20 years of age. This may be related to the increased use of alcohol and drugs of abuse in this age group.

Epidemiology Marital Status

• Major depressive disorder occurs most often in persons without close interpersonal relationships and in those who are divorced or separated.

• Bipolar I disorder is more common in divorced and single persons than among married persons, but this difference may reflect the early onset and the resulting marital discord characteristic of the disorder.

Epidemiology Socioeconomic and Cultural Factors

• No correlation has been found between socioeconomic status and major depressive disorder.

• A higher than average incidence of bipolar I disorder is found among the upper socioeconomic groups.

Comorbidity

• Individuals with major mood disorders are at an increased risk of having one or more additional comorbid disorders.

• The most frequent disorders are alcohol abuse or dependence, panic disorder, obsessive-compulsive disorder (OCD), and social anxiety disorder.

• Conversely, individuals with substance use disorders and anxiety disorders also have an elevated risk of lifetime or current comorbid mood disorder.

Comorbidity

• In both unipolar and bipolar disorder, whereas men more frequently present with substance use disorders, women more frequently present with comorbid anxiety and eating disorders.

• In general, patients who are bipolar more frequently show comorbidity of substance use and anxiety disorders than do patients with unipolar major depression.

Comorbidity

• Comorbid substance use disorders and anxiety disorders worsen the prognosis of the illness and markedly increase the risk of suicide among patients who are unipolar major depressive and bipolar.

Depressive Disorders

Depressive Disorders

• Disruptive Mood Dysregulation Disorder

• Major Depressive Disorders

• Persistent Depressive Disorders

• Premenstrual Dysphoric Disorder

• Substance/Medication-induced Depressive Disorder

• Depressive Disorder Due to Another Medical Condition

• Other Specified Depressive Disorder

• Unspecified Depressive Disorder

Major Depressive Disorders

DSM-5 Criteria for Major Depressive Disorder

A. 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 symptom is either (1) depressed mood or (2) loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e. g., appears tearful). (Note: In children and adolescents, can be irritable mood.) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).


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 in appetite nearly every day. 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 every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach 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.


B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or to another medical condition


D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or a hypomanic episode.

Epidemiology

• Life time prevalence rate for major depression: 5-17 %

• F: M ratio is 2:1

ETIOLOGY

• Biological Factors

Biogenic Amines. Of the biogenic amines, norepinephrine and serotonin are the two neurotransmitters most implicated in the pathophysiology of mood disorders.

• Depression is associated with dysregulation of serotonin (5-HT) and noradrenaline ( NA ) in the CNS.

A proposed model of symptoms mediated by 5-HT and NA

Sexual behavior Aggression Appetite Impulsivity

Sleep Concentration Aches & pains Energy Cognitive function Motivation Learning Vigilance Mood Anxiety

Serotonin (5-HT) Noradrenaline (NA)

Genetic factors

• Family studies: If one parent has a mood disorder, a child will have a risk of between 10 and 25 % for mood disorder.

• Twin studies: Concordance rate for mood disorder in the monozygotic (MZ) twins of 70 to 90 %.

• A family history of bipolar disorder conveys a greater risk for mood disorders in general and, specifically, a much greater risk for bipolar disorder .

• Unipolar disorder is typically the most common form of mood disorders in families of bipolar probands.

Psychosocial factors

• Life events and environmental stress. Some clinicians believe that life events play the primary or principal role in depression; others suggest that life events have only a limited role in the onset and timing of depression. The life event most often associated with development of depression is losing a parent before age 11 years. The environmental stressor most often associated with the onset of depression is the loss of a spouse. Another risk factor is unemployment .

Cognitive Theory

• Aoron Beck postulated a cognitive triad of depression that consists of:

(1) View about the self-a negative self-percept (2) About the environment- a tendency to

experience the world as hostile and demanding (3) About the future0the expectation of suffering

and failure Cognitive therapy consists of modifying these distortions.

• With anxious distress

• With mixed features

• With melancholic features

• With atypical features

• With psychotic features

• With catatonia

• With peripartum onset

• With seasonal pattern

DSM-5 Specifiers for Bipolar and Related Disorders and Depressive Disorders


• Specify if: With anxious distress: The presence of at least two of the following symptoms during the majority of days of the current or most recent episode of mania, hypomania, or depression: 1. Feeling keyed up or tense. 2. Feeling unusually restless. 3. Difficulty concentrating because of worry. 4. Fear that something awful may happen. 5. Feeling that the individual might lose control of himself or herself.


• Specify if: With rapid cycling (can be applied to bipolar I or bipolar II disorder):

Presence of at least four mood episodes in the previous 12 months that meet the criteria for manic, hypomanic, or major depressive episode.

• Specify if: With melancholic features: A. One of the following is present during the most severe period of the current episode: 1. Loss of pleasure in all, or almost all, activities. 2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens). • B. Three (or more) of the following: • 1. A distinct quality of depressed mood characterized by profound

despondency, • despair, and/or moroseness or by so-called empty mood. • 2. Depression that is regularly worse in the morning. • 3. Early-morning awakening (i.e., at least 2 hours before usual awakening). • 4. Marked psychomotor agitation or retardation. • 5. Significant anorexia or weight loss. • 6. Excessive or inappropriate guilt.

With melancholic features

A. One of the following is present during the most severe period of the current episode:

1. Loss of pleasure in all, or almost al, activities.

2. Lack of reactivity to usually pleasurable stimuli( doesn’t feel much better, even temporarily, when something good happens).

B. Three (or more) of the following: 1. A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood. characterized by 2. Depression that is regularly worse in the morning. 3. Early-morning awakening(i.e., at least two hours before usual awakening). 4. Marked psychomotor agitation or retardation. 5. Significant anorexia or weight loss. 6. Excessive or inappropriate guilt.

Melancholic depression

• A severe form of depression.

• Often recurrent.

• Accompanied by psychotic features in 10%-15% of patients.

• More common after 50 years of age.

• Typically responsive to somatic therapies.

With atypical features: This specifier can be applied when these features predominate during the majority of days of the current or most recent major depressive episode. A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events). B. Two (or more) of the following features: 1. Significant weight gain or increase in appetite. 2. Hypersomnia. 3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs). 4. A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment.

With atypical features Clinical features

• Early age at onset.

• Chronic course.

• Higher frequency in females.

• Higher frequency in patients with borderline personality disorder.

• Good response to SSRIs, bupropion and MAOIs but not to TCAs.

• Specify if With psychotic features: Delusions or hallucinations are present at any time in the episode. • If psychotic features are present, specify if mood-congruent or mood-

incongruent: With mood-congruent psychotic features: During manic episodes, the content of all delusions and hallucinations is consistent with the typical manic themes of grandiosity, invulnerability, etc., but may also include themes of suspiciousness or paranoia, especially with respect to others’ doubts about the individual’s capacities, accomplishments, and so forth. With mood-incongruent psychotic features: The content of delusions and hallucinations is inconsistent with the episode polarity themes as described above, or the content is a mixture of mood-incongruent and mood-congruent themes.

With peripartum onset: This specifier can be applied to the current or, if the full criteria are not currently met for a mood episode, most recent episode of mania, hypomania, or major depression in bipolar I or bipolar II disorder if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery.

Peripartum-onset mood episodes can present either with or without psychotic features. Infanticide is most often associated with postpartum psychotic episodes that are characterized by command hallucinations to kill the infant or delusions that the infant is possessed, but psychotic symptoms can also occur in severe postpartum mood episodes without such specific delusions or hallucinations. Postpartum mood (major depressive or manic) episodes with psychotic features appear to occur in from 1 in 500 to 1 in 1,000 deliveries and may be more common in primiparous women. The risk of postpartum episodes with psychotic features is particularly increased for women with prior postpartum mood episodes but is also elevated for those with a prior history of a depressive or bipolar disorder (especially bipolar I disorder) and those with a family history of bipolar disorders. Once a woman has had a postpartum episode with psychotic features, the risk of recurrence with each subsequent delivery is between 30% and 50%.

With seasonal pattern: This specifier applies to the lifetime pattern of mood episodes.

The essential feature is a regular seasonal pattern of at least one type of episode (i.e., mania, hypomania, or depression). The other types of episodes may not follow this pattern.

For example, an individual may have seasonal manias, but his or her depressions do not regularly occur at a specific time of year.

With seasonal pattern

• A. There has been a regular temporal relationship between the onset of major depressive episodes in major depressive disorder and a particular time of the year (e.g., in the fall or winter). Note: Do not include cases in which there is an obvious ef fect of seasonally related psychosocial stressors (e.g., regularly being unemployed every winter). B. Full remissions (or a change from major depression to mania or hypomania) also occur at a characteristic time of the year (e.g., depression disappears in the spring). C. in the last 2 years, two major depressive episodes have occurred that demonstrate the temporal seasonal relationships defined above and no nonseasonal major depressive episodes have occurred during that same period. D. Seasonal major depressive episodes (as described above) substantially outnumber the nonseasonal major depressive episodes that may have occurred over the individual's lifetime.

Depressive episodes and Suicide

• About two-thirds of all depressed patients Contemplate suicide and 10-15% commit suicide.

Medical disorders associated with depression

• Hypothyroidism

• Cushing’s disease

• Diabetes

• Autoimmune disorders (systemic lupus erythematosus, rheumatoid arthritis, multiple sclerosis)

• Myocardial infarction and cardiovascular disease

• Cerebrovascular accident

• Parkinson’s disease

• Cancer (pancreatic CA, lymphoma)

• Dementia

Common substances associated with depression

• Alcohol

• Stimulants( cocaine, methamphetamine)

• Opiates

• Prescription medications ( steroids, beta- blockers, methyldopa, digitalis, benzodiazepine, interferon)

Distinguishing grief from major depressive episode ( MDE)

• In grief the predominant affect is feelings of emptiness and loss, while in a MDE it is persistent depressed mood and inability to anticipate happiness or pleasure.

• The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves. The depressed mood of an MDE is more persistent and not tied to specific thoughts or preoccupations.


• The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than self-critical or pessimistic ruminations seen in an MDE.

• In grief, self-esteem is generally preserved, whereas in an MDE, feelings of worthlessness and self-loathing are common.


• If self-derogatory ideation is present in grief, it typically involves ( not visiting frequently enough, not telling the deceased how much he or she was loved). If bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly abut “joining” the deceased. Whereas in an MDE, such thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.

Course ONSET

About 50 percent of patients having their first episode of major depressive disorder exhibited significant depressive symptoms before the first identified episode.

The first depressive episode occurs before age 40 years in about 50 percent of patients.

A later onset is associated with the absence of a family history of mood disorders, antisocial personality disorder, and alcohol abuse.

Course DURATION

• An untreated depressive episode lasts 6 to 13 months

• Most treated episodes last about 3 months.

• The withdrawal of antidepressants before 3 months has elapsed almost always results in the return of the symptoms.

• As the course of the disorder progresses, patients tend to have more frequent episodes that last longer.

• Over a 20-year period, the mean number of episodes is five or six.

Course Prognosis

• Major depressive disorder is not a benign disorder.

• It tends to be chronic, and patients tend to relapse.

• The incidence of relapse is lower than these figures in patients who continue prophylactic psychopharmacological treatment and in patients who have had only one or two depressive episodes.

• Generally, as a patient experiences more and more depressive episodes, the time between the episodes decreases, and the severity of each episode increases.

Persistent Depressive Disorder (Dysthymia)


A. Depressed mood for most of the day, for more days than not for at least two years. In children and adolescents, mood can be irritable and duration must be at least one year.

B. Presence, while depressed, of two (or more) of the following: 1. Poor appetite or overeating. 2. Insomnia or hypersomnia. 3. Low energy or fatigue. 4. Low self-esteem. 5. Poor concentration or difficulty making decisions. 6. Feelings of hopelessness.


C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time. D. Criteria for a major depressive disorder may be continuously present for 2 years


E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.

F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.


G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism).

H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.


• Affects 5 to 6 % of all persons.

• No gender differences are seen for incidence rates. The disorder is more common in women younger than 64 years of age than in men of any age and is more common among unmarried and young persons and in those with low incomes.

Disruptive Mood Dysregulation Disorder (DMDD)

This diagnosis can be considered for individuals ages 6–18 years

who present with severe recurrent temper outbursts with intermittent irritable or angry mood, but whose symptoms never meet lifetime criteria for a manic or hypomanic episode, oppositional defiant disorder, or intermittent explosive disorder.

Bipolar and Related Disorders

DSM- 5 Bipolar and Related Disorders

• Bipolar I Disorder

• Bipolar II Disorder

• Cyclothymic Disorder

• Substance/Medication-induced Bipolar and Related Disorder

• Bipolar and Related Disorder Due to Another Medical Condition

• Other Specified Bipolar and Related Disorder

• Unspecified Bipolar and Related Disorder

Bipolar I Disorder

Bipolar I Disorder DSM-5 Diagnostic criteria

• Manic episode:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least one week and persistent most of the day, nearly every day.

B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:


B. 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 subjective experience that thoughts are racing

5. Distractibility (attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.

6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (purposeless non-goal-directed activity)

7. Excessive involvement in activities that have high potential for painful consequences (engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

• Manic episode:

C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.



A. Criteria have been met for at least one manic episode ( Criteria A-D under “manic episode”)

B. The occurrence of the manic and major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder.

• At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.

Bipolar I disorder Clinical issues

• Bipolar I disorder is an episodic, incurable illness with a variable course and variable outcome. Even with treatment, outcomes can be poor, with high depressive rates of relapse, persistence of residual symptoms after an acute manic or depressive episode, increased potential for cognitive loss, marked functional and psychosocial impairment, and high rates of suicide.


• Substance abuse is very common (as high as 70%).

• Interepisode moods are more likely depressed than euthymic by a ratio of 3:1.

• There is strong genetic component to the transmission of the disorder.


• An earlier age of onset of the first bipolar episode correlates with increased chronicity and overall greater functional impairment.

• Onset of a manic episode is typically rapid (hours or days). Untreated, a manic episode typically lasts 3-4 months and a bipolar depressive episode typically lasts 6-9 months.


• Prognosis is poor for persons with:

A rapid cycling pattern.

Active substance abuse.

Psychotic symptoms during the manic episode or severe depressive episodes.

Male gender.

A younger age at initial onset.

Increasing frequency of bipolar episodes.

Low occupational status.


• Always rule out secondary causes of mania before making a diagnosis of bipolar disorder:

Medications(e.g., corticosteroids, methylphenidate, thyroid medications).

Drugs (e.g., cocaine). Endocrine disorders (e.g., hyperthyroidism,

Cushing’s disease). Neurological disorders (e.g., head injury,

neoplasms, cerebral vascular accident). Infections (e.g., meningitis).

Bipolar I disorder Course

• Bipolar I disorder most often starts with depression (75 percent of the time in women, 67 percent in men) and is a recurring disorder.

Prognosis

• Patients with bipolar I disorder have a poorer prognosis than do patients with major depressive disorder.

• About 40 to 50 percent of patients with bipolar I disorder may have a second manic episode within 2 years of the first episode.

• About 7 percent of patients with bipolar I disorder do not have a recurrence of symptoms; 45 percent have more than one episode, and 40 percent have a chronic disorder.

Prognosis

• Short duration of manic episodes, advanced age of onset, few suicidal thoughts, and few coexisting psychiatric or medical problems predict a better outcome.

Bipolar II disorder

Bipolar II disorder

• Basic diagnostic requirements are for the presence of at least one hypomanic episode, but without a history of a manic episode, and the presence of one or more major depressive episodes.

Bipolar II disorder DSM-5 Diagnostic criteria

Hypomanic episode: A. A distinct period of abnormally and persistently elevated,

expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.

B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree:


Hypomanic episode: B. 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only 3 hours of

sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or

irrelevant external stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or

school, or sexually) or psychomotor agitation. 7. Excessive involvement in activities that have a high potential for

painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).


• Hypomanic episode:

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. 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. if there are psychotic features, the episode is, by definition, manic . F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment).

Bipolar II disorder Epidemiology

• Found in 0.3% -2% of the general populations.

• More prominent in females than males by a ratio of 3 to 1.

Bipolar II disorder Clinical issues

• The presence or history of a single manic episode precludes the diagnosis of bipolar II disorder.

• Unlike bipolar I disorder, bipolar II disorder requires at least one depressive episode.

• Bipolar II disorder is not a milder form of bipolar I disorder.

Rapid cycling

• Rapid cycling requires at least four mood episodes over the previous 12 months.

• Is a specifier applicable to bipolar I and II disorders, not a specific disorder(e.g., bipolar I disorder with a rapid cycling pattern).

Cyclothymic Disorder DSM-5 Diagnostic criteria

• A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time. C. Criteria for a major depressive, manic, or hypomanic episode have never been met.

Cyclothymic Disorder DSM-5 Diagnostic criteria

D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Cyclothymic Disorder Epidemiology

• The life time prevalence of cyclothymic disorder is estimated to be around 1 percent.

• Female to male ratio is about 3 to 2.

• 50- 75 percent of all patients have an onset between ages 15 and 25 years.

THE END

Mood disorders - كلية الطب•Individuals with major mood disorders are at an increased risk...

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Transcript of Mood disorders - كلية الطب•Individuals with major mood disorders are at an increased risk...