mood disorders

Mood Disorders

M.S Sara Dawod

Introduction

• Mood disorders referred to it as affective disorders and divided into two main categories: depressive disorders and bipolar disorders.

• Depression could be the primary problem or secondary to other problem.

• Depression affect F]M , Lower class.• Mania: M=F• Mania incidence increases with age and occur more

in high class, divorced persons, starts late adolescence and early twenties.

Introduction

• Depression can occur at any age.• Infant: withdrawal, non-responsive, depression,

vulnerability to physical illness or failure to thrive when separated from the mother.

• School aged: hyperactivity, social phobia, excessive clinging to parents.

• Adolescents: poor academic achievement, abuse substances, antisocial behaviors, attempt suicide, running away.

Mood disorders

• Disorders that have a disturbance in mood:• Major depressive episode.• Manic episode.• Mixed episode.• Hypomanic episode.• Major depressive disorder.• Dysthymic disorder.• Bipolar disorder.

Major depressive episode

• Five or more of the following symptoms have been present during the same 2 weeks (persist most of the day, nearly every day, for at least two weeks), at least one of the symptoms depressed mood and loss of interest or pleasure.

1. Depressed most of the day (children and adolescents: irritable).

2. Diminish interest or pleasure in all activities.3. Weight loss or gain.

Major depressive episode

4. Insomnia or hypersomnia.5. Psychomotor agitation.6. fatigue.7. Worthlessness or excessive guilt.8. Inability to concentrate or think.9. Recurrent thought of death or suicide.10. Symptoms cause impairment in social, occupational or other functions.

Manic episode

• Period of abnormally elevated mood lasting at least one week.

• During the period of mood disturbances, 3 or more of the following symptoms persist:

1. Inflated self esteem or grandiosity.2. Decrease sleep.3. Talkative than usual.4. Flight of ideas.

Manic episode

5. distractibility.6. Increase in goal directed activity.7. Excessive involvement in pleasure activity that have painful consequences.• Note: the symptoms should be severe enough

to cause impairment in social or occupational functions or to require hospitalization.

Mixed episode

• Period of time in which criteria are met for manic episode and for major depressive episode nearly every day for at least 1 week which may cause impairment in occupation or social activities, or relations or need hospitalization to prevent harm.

• Common in males than females.• Common in younger person than old over 60

years.

Mixed episode

• Differential diagnosis:• Substance induced mood disorder.• Mood disorder due to general medical

condition.• Attention deficit/hyperactivity disorder (early

onset before 7 years, chronic rather than episodic, lack of elevated mood).

Major depressive disorder

• Is characterized by one or more major depressive episodes without history of manic, mixed, or hypomanic episodes.

• Diagnostic criteria: for single episode: the presence of single major depressive episode.

• For current: two or more episodes.• It is not better accounted for by schizoaffective

disorders.• There has been never a manic or hypomanic

episode.

Hypomania episode • Period of persistently elevated or irritable mood lasting

throughout at least 4 days and 3 or more of the following symptoms are present:

1. Grandiosity or inflated self-esteem.2. Decrease need for sleep.3. Talkative than usual.4. Flight of ideas.5. distractibility.6. Increase in goal directed activity.7. Excessive involvement in pleasure activity that have painful

consequences.• Not sever enough to cause marked impairment in social or

occupational functioning or hospitalization.

Hypomania episode

• Sudden onset, and rapid escalation of symptoms within one or two days.

• Differential diagnosis:• Substance induced mood disorder.• Mood disorder due to general medical

condition.• Attention deficit/hyperactivity disorder (early

diagnosis before 7 years, absence of elevated mood, chronic).

Dysthymic disorder • Chronically depressed mood that occurs for most of the day for

at least 2 years and presence of two or more of the following:1. Poor appetite or overeating.2. Insomnia or hypersomnia.3. Fatigue, low self-esteem.4. Poor concentrating.5. Feeling of helplessness.• These symptoms have been present at least for 2 months

during the 2 years period.• Mood: in adult: sad or down.• Children and adolescents: irritable and minimal duration 1 year.

Bipolar I disorder

• The occurrence of one or more of manic episodes or mixed episodes.

• Onset: 20 years: M&F.

Bipolar II disorder

• Characterized by the occurrence of one or more major depressive episodes and at least one hypomania episodes.

• Common in females than men.

Differences between unipolar and bipolar

• Unipolar : symptoms of major depression.• Bipolar: bipolar I & II.

Etiology of mood disorders • Neurobiological factors including:• Genetics.• Neurotransmitters: low level of norepinephrine, serotonin

and dopamine for depression and high level of norepinephrine and dopamine for mania. Resprime drugs(calm agitated schizophrenia) decrease norepinephrine and serotonin.

• Neuroendocrine system: overactive hypothalamic pituitary adrenal cortex which may lead to high level of cortisol and causing depression. Dexamthasone suppresses the release of cortisol and improve depression. Hypothyroidism.

Etiology of mood disorders • Interpersonal theory (social factors): stressful life

events, interpersonal problems, decrease social support, feeling of rejection by others.

• Psychological factors: including:• Psychoanalytic theory(freud): emphasize the

unconscious conflicts associated with grief and loss.• Freud hypothesized that the potential for depression

is created early in childhood during oral stage. If the child's needs are insufficiently, the person are become fixed at the oral stage and become dependent on others for self-esteem.

Etiology of mood disorders

• After the loss of loved person, the mourner identifies with the lost one (introject) to undo the loss and unconsciously resent being deserted and feel anger toward the loved one for loss and feel guilt for real or imagined sin against the lost person.

• In the mourning work, the mourner recall memories of the lost one and separate himself from the died person.

Etiology of mood disorders

• However, some may don’t loosen their emotional bond with the died person and the anger toward the lost one is directed inward, developing ongoing self-blame and depression (depression is anger turned against oneself).

• Little researches supported this theory.

Etiology of mood disorders

• For mania: manic episodes are viewed as defense reaction against depression or due to superego intolerable self criticism which is replaced by euphoria or ego overwhelmed by pleasure impulses such as sex or aggression.

Etiology of mood disorders

• Cognitive theory: negative thought and beliefs are the major cause of depression.

• Becks theory: people develop depression because their thinking is negative. Depression is associated with negative triad: negative views of self, world, and future.

Etiology of mood disorders

• In childhood people with depression acquired negative schemata: tendency to view the world negatively through stressful life events.

• This schema is activated whenever similar situation occurs.

Etiology of mood disorders

• Cognitive error:• Arbitrary inference: drawing a conclusion in the

absent of sufficient evidence (rain & party).• Selective abstraction: drawing a conclusion by

focusing on one element only and ignoring others (bad products and many workers).

• Overgeneralization: drawing a sweeping conclusion on the basis of single event (one exam result).

Etiology of mood disorders

• Magnification and minimization: gross error in evaluating performance (car scratch or feel worthless in spite of successful achievement).

• Some studies didn’t support this theory especially the causal relation between depression and negative thinking.

Psychological treatment of depression

• The therapist should confront the moral and the political implication of his/her work whether to help the client to alter his/her situation life or to help her/him to adjust.

• Depression can be a healthy sign for a client who is ready to make changes.

Psychological treatment of depression

• Interpersonal psychotherapy: it focus on interpersonal problems and persons current life and not the past problem in childhood. It is short term (16 sessions).

• Focus: discussion of interpersonal problems, exploration of negative feelings, improving verbal and non-verbal communication, problem solving.

Psychological treatment of depression

• Cognitive therapy: to alternate maladaptive thought. The therapist helps the persons to change their opinions about life and self and monitor their negative thought. Also teach the person to challenge negative beliefs.

• Behavioral techniques: do things such as get out of bed, and the people are given an assignment. This therapy is superior to drug therapy for unipolar depression.

Psychological treatment of depression

• Social skills training.

• Psychoanalytic: help the patient to have insight into repressed conflict and release of inward hostility such as blame himself for the death of person by confronting the facts that he has this belief, recover memories from stressful event and feeling of inadequacy (not significant therapy).

Biological treatment for mood disorders

• Somatic therapy: electroconvulsive therapy (ECT) for severe depression: passing current 70-130 volts, giving the pt muscle relaxant and anesthesia before performing it: risk short term confusion and memory loss.

Medication • Tricyclic and Monoamine oxidase inhibitors (e.g.

parnate) increase serotonin and norepinephrine.• Tricyclic antidepressant: imipramine (Tofranil) and

amitriptyline (Elavil). It takes from 4-5 weeks to work.

• Side effects: death, arrhythmia, orthostatic hypertension, palpitation, tachycardia, sedation, fatigue, low energy, ataxia, weight gain and blurred vision.

Medication

• Selective serotonin reuptake inhibitor: (prozac 10-80 mg).

• Side effects: monitor hepatic and renal function, DM, headache, weight loss, GI and sleep disturbances.

Medication

• For mania: lithium carbonate (900-1800 mg): it affect the renal (nephrotoxicity, heart and thyroid-weakness, neurotoxicity, so ensure adequate fluid intake, monitor ECG, hand tremor, slurred speech, muscle weakness, polyuria, TSH, blood account.

• Neuroleptic.