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MOOD DISORDERS

HYACINTH C. MANOOD, MD, FPPA


• 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.


• A syndrome consisting of a cluster of
signs and symptoms sustained over
weeks to months, which represent a
marked departure from a person’s
functioning, and tend to recur, often in
periodic or cyclical fashion.
• 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
• 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
MOOD DISORDER LIFETIME PREVALENCE
Major Depressive Disorder F = 10 – 25%
M = 5 – 12%

Bipolar I disorder 0.4 – 1.6%

Bipolar II disorder 0.5

Dysthymia 6%

Cyclothymia 0.4 – 1.0%


• 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
• onset of bipolar I disorder is earlier than that
of major depressive disorder

• mean age of 30 for bipolar 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
• 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
ETIOLOGY
I. Biological Factors
A. Biogenic Amines
1. NOREPINEPHRINE
- downregulation or decreased sensitivity
of ß-adrenergic receptors ; presynaptic
ß2- receptors

2. SEROTONIN
- most commonly associated with
depression
- depletion of serotonin may precipitate
depression
3. DOPAMINE
- reduced in depression; increased in mania;
D1 receptors and mesolimbic dopamine
pathway.

4. OTHERS
- Abnormal levels of choline
- Reductions of GABA
- G proteins or other second messengers.
- Hypercortisolema
- elevated basal thyroid-stimulating hormone
(TSH) level or an increased TSH response to
a 500-mg infusion of the hypothalamic
neuropeptide thyroid-releasing hormone
(TRH).

- Decreased CSF somatostatin levels have


been reported in depression, and increased
levels have been observed in mania.
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


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

1. Life Events and Environmental Stress


- The life event most often associated with
development of depression is losing a parent before
age 11.
- The environmental stressor most often associated
with the onset of an episode of depression is the
loss of a spouse.

2. Personality Factors
- Persons with certain personality disorders: OCD,
histrionic, and borderline, may be at greater risk for
depression
3. Cognitive Theory
Aaron Beck postulated a cognitive triad of
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.
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
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
Major Depressive Episode
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 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 excessive or 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
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
Manic Episode
A. A distinct period of abnormally and persistently elevated,
expansive, or irritable mood, lasting at 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;
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.
Hypomanic Episode

A. A distinct period of persistently elevated, expansive, or


irritable mood, lasting throughout at 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.
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
MIXED EPISODE

A. The criteria are met both for a manic episode and for a
major depressive episode nearly every day during at
least a 1-week period.

B. 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;

C. The symptoms are not due to the direct physiological


effects of a substance or a general medical condition.
MAJOR DEPRESSIVE DISORDER

A. If single episode – presence of a single MDE;


If recurrent – 2 or more MDE’s.

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.
BIPOLAR I DISORDER(single manic episode)

A. Presence of only one manic episode and no


past MDE.

A. 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;
BIPOLAR I DISORDER
(most recent episode ________)
A. Currently or most recently in a ________ episode.

B. There has previously been at least one of the other


episodes.

C. 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;
BIPOLAR II DISORDER
A. Presence or history on one or more MDE.

B. Presence or history of at least one hypomanic episode.

C. There has never been a manic or mixed episode.

D. 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;

E. The symptoms cause clinically significant distress or


impairment in social, occupational, or other important
areas of functioning.
DSM-IV-TR Diagnostic Criteria for
Dysthymic Disorder
A. 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.

B. 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
C. 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.
D. 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
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.
G. 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).
H. The symptoms cause clinically significant
distress or impairment in social, occupational,
or other important areas of functioning.
DSM-IV-TR Diagnostic Criteria for
Cyclothymic Disorder
A. 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.
B. 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.
C. 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).
D. 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.
E. 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).
F. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
TREATMENT
GOALS
• Patient’s safety must be guaranteed.

• Complete diagnostic evaluation

• Treatment plan addressing not just


immediate symptoms but patient’s
prospective well-being.
I. 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 patient’s usual support system
II. Psychosocial Therapy
1.Cognitive Therapy
2.Interpersonal Therapy
3.Behavior Therapy
4.Psychoanatically-oriented Therapy
5.Family Therapy
III. Pharmacotherapy

A.Major Depressive Disorder


- MAOI’s, TCAC’s, SSRI’s, SNRI’s
B. Bipolar Disorders
- Lithium, anticonvulsants, antipsychotics
THANK YOU & GOOD DAY

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