MOOD DISORDERS

Prof.Manimegalai Rajamohan,
Principal,
SCPM College of Nursing,
Gonda

Mood disorders are characterized by a disturbance of mood, accompanied by a full or partial

manic or depressive syndrome, which is not due to any other physical or mental disorder. The
prevalence rate of mood disorders is 1.5 percent, and it is uniform throughout the world
Classification of Mood Disorders
According to ICD lO (F3) mood disorders are classified as follows:
• Manic episode
• Depressive episode
• Bipolar mood (affective)disorders
• Recurrent depressive disorder
• Persistent mood disorder (including cyclothymia and dysthymia)
• Other mood disorders
Etiology
Biological Theories
Genetic hypothesis Genetic factors are very important in predisposing an individual to mood
disorders. The lifetime risk for the first-degree relatives of patients with bipolar mood disorder
is 25%and of normal controls is 7% .The lifetime risk for the children of one parent with mood
disorder is 27%and of both parents with mood disorder is 74%. The concordance rate for
monozygotic twins is65%and for dizygotic twins is 15%.
Biochemical theories A deficiency of norepinephrine and serotonin has been found in
depressed patients and they are elevated in mania. Dopamine, GABA and acetylcholine are
also presumably involved.
Psychosocial Theories
Psychoanalytic theory According to Freud (1957) depression results due to loss of a "loved
object", and fixation in the oral sadistic phase of development. In this model, mania is viewed
as a denial of depression.
Behavioural theory: This theory of depression connects depressive phenomena to the
experience of uncontrollable events. According to this model, depression is conditioned by
repeated losses in the past.
Cognitive theory According to this theory depression is due to negative cognitions which
includes: Negative expectations of the environment Negative expectations of the self-Negative
expectations of the future These cognitive distortions arise out of a defect in cognitive
development and cause the individual to feel inadequate, worthless and rejected by others.
Sociological theory Stressful life events,e.g.death, marriage, financial loss before the onset of
the disease or a relapse probably have a formative effect.

Manic Episode
Mania refers to a syndrome in which the central features are over-activity, mood change
(which may be towards elation or irritability) and self-important ideas.
Classification of Mania (ICD10)
• Hypomania
• Mania without psychotic symptoms
• Mania with psychotic symptoms
• Manic episode unspecified
Clinical Features
An acute manic episode is characterized by the following features which should last for at least
one week:
Elevated, Expansive or Irritable Mood Elevated mood in mania has four stages depending on
the severity of manic episodes:
• Euphoria (StageI): Increased sense of psychological well-being and happiness not in keeping
with ongoing events.
• Elation (StageII): Moderate elevation of mood with increased psychomotor activity.
• Exaltation (StageIII): Intense elevation of mood with delusions of grandeur.
• Ecstasy (StageIV): Severe elevation of mood, intense sense of rapture or blissfulness seen in
delirious or stuporous mania. Expansive mood is unceasing and unselective enthusiasm for
interacting with people and surrounding environment. Sometimes irritable mood may be
predominant, especially when the person is stopped from doing what he wants. There may be
rapid, short-lasting shifts from euphoria to depression or anger.
Psychomotor Activity There is an increased psychomotor activity ranging from over
activeness and restlessness to manic excitement. The person involves in
ceaselessactivity.Theseactivitiesare goal-oriented and based on external environment cues.
Speech and Thought
• Flight of ideas: Thoughts racing in mind, rapid shifts from one topic to another
r • Pressure of speech: Speech is forceful, strong and difficult to interrupt. Uses playful
language with punning, rhyming, joking and teasing and speaks loudly
• Delusions of grandeur
• Delusions of persecution
• Distractibility
Other Features
• Increased sociabilities
• Impulsive behavior
• Disinhibition
• Hypersexual and promiscuous behavior
• Poorjudgment
• High-risk activities (buying sprees, reckless driving, foolish business investments,
distributing money or articles to unknown persons)
• Dressed up in gaudy and flamboyant clothes although in severe mania there may be poor self-
care • Decreased need for sleep (< 3hrs)
• Decreased food intake due to over-activity
• Decreased attention and concentration
• Poor judgment
• Absent insight
Symptoms of Hypomania
Hypomania is a lesser degree ofmania. There is a persistent mild elevation of mood and
increased sense of psychological wellbeing and happiness not in keeping with ongoing events.
The features of hypomania may be specified as follows:
1. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout
days, that is clearly different from the usual non-depressed mood.
2. During the period of mood disturbance, three (or more) of the following symptoms are
persistent (four, if the mood is only irritable) and present to a significant degree:
a) inflated self-esteem or grandiosity
b) decreased need for sleep (e.g. Feels rested after only 3hours of sleep)
c) more talkative than usual
d) flight of ideas or subjective experience that thoughts are racing
e) distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli
f) increase in goal-directed activity (either socially,at work or school,or sexually) or
psychomotor agitation
g) excessive involvement in pleasurable activities that have ahigh potential for painful
consequences (e.g. The person engages in unrestrained buying sprees, foolish business
investments or sexual indiscretions)
3. The episode is associated with an unequivocal change in functioning that is uncharacteristic
of
the person when not symptomatic.
4.The disturbance in mood and the change in functioning are observable by others. 5. 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.
Treatment
Pharmacotherapy
• Lithium: 900-2100 mg/ day.
• Carbamazepine: 600-1800 mg/day.
• Sodium valproate: 600-2600 mg/ day.
• Other drugs: Clonazepam, calcium channel blockers, etc.
(referchapter14formoredetailsonthesedrugs)
Electroconvu/sive Therapy (ECT) ECTcan also be used for acute manic excitement if not
adequately responding to antipsychotics and lithium.
Psychosocial Treatment Family and marital therapy is used to decrease intrafamilial and
interpersonal difficulties and to reduce or modify stressors. The main purpose is to ensure
continuity of treatment and adequate drug compliance.
Depressive Episode Depression is a widespread mental health problem affecting many people.
The lifetime risk of depression in males is 8 to 12%and in females it is20to26%. Depression
occurs twice as frequently in women as in men.
Classification of Depression (ICD10)
• Mild depression
• Moderate depression
• Severe depression
• Severe depression with psychotic symptoms
Clinical Features
A typical depressive episode is characterized by the following features, which should last for
at least two weeks in order to make a diagnosis:
Depressed mood: Sadness of mood or loss of interest and loss of pleasure in almost all
activities (pervasive sadness), present throughout the day (persistent sadness).
Depressive cognitions: Hopelessness (a feeling of 'no hope in future' due to pessimism),
helplessness (the patient feels that no help is possible), worthlessness (a feeling of inadequacy
and inferiority), unreasonable guilt and self-blame over trivial matters in the past.
Suicidal thoughts: Ideas of hopelessness are often accompanied by the thought that life is no
longer worth living and that death had come as a welcome release. These gloomy
preoccupations may progress to thoughts of and plans for suicide
Psychomotor activity: Psychomotor retardation is frequent. The retarded patient thinks, walks
and acts slowly. Slowing of thought is reflected in the patient’s speech; questions are often
answered after a long delay and in a monotonous voice. In older patients’ agitation is common
with marked anxiety, restlessness and feelings of uneasiness.

Psychotic features: Some patients have delusions and hallucinations (the disorder may then
be termed as psychotic depression); these are often mood congruent, i.e. they are related to
depressive themes and reflect the patient’s dysphoric mood. For example, nihilistic delusions
(beliefs about
the non-existence of some person or thing), delusions of guilt, delusions of poverty, etc. may
be present.

Some patients experience delusions and hallucinations that are not clearly related to
depressive themes (mood incongruent), for example, delusion
of control. The prognosis then appears to be much worse.

Somatic symptoms of depression, according to ICD10 (these are called as ‘melancholic

features’ in DSMIV):

¢ Significant decrease in appetite or weight.

* Early morning awakening, at least 2 or more hours before the usual time of waking up.

¢ Diurnal variation, with depression being worst in the morning.

¢ Pervasive lack of interest and lack of reactivity to pleasurable stimuli.

* Psychomotor agitation or retardation.

Other Features

• Difficulties in thinking and concentration.

• Subjective poor memory.
• Menstrual or sexual disturbances.
• Vague physical symptoms such as fatigue,
 aching discomfort, constipation.

Treatment

Pharmacotherapy

Antidepressants

Electroconvulsive therapy (ECT)

Severe depression with suicidal risk is the most

important indication for ECT (See Chapter 14, pg
182,).

Psychosocial Treatment

* Cognitive therapy: It aims at correcting the depressive negative cognitions like

hopelessness, worthlessness, helplessness and pessimistic ideas, and replacing them with new
cognitive and behavioral responses.

© Supportive psychotherapy: Various techniques are employed to support the patient. They
are reassurance, ventilation, occupational herapy, relaxation and other activity therapies.

* Group therapy: Group therapy is useful for mild cases of depression. In group therapy
negative feelings such as anxiety anger, guilt, despair are recognized and emotional growth is
improved through expression of their
feelings.

« Family therapy: Family therapy is used to decrease intrafamilial and interpersonal

difficulties and to reduce or modify stressors, which may help in faster and more complete
recovery.

© Behavior therapy: It includes social skills training, problem solving techniques,

assertiveness training, self-control therapy, activity scheduling and decision-making
techniques.

Course and Prognosis of Mood Disorders

An average manic episode lasts for 3-4 months, while a depressive episode lasts for 4-9 months.

OTHER MOOD DISORDERS

Bipolar Mood Disorder

This is characterized by recurrent episodes of mania and depression in the same patient at
different times.

Bipolar mood disorder is further classified into bipolar I and bipolar Il disorder (DSMIV).
Bipolar I: Episodes of severe mania and severe depression.
 Bipolar II: Episodes of hypomania and severe depression.

Recurrent Depressive Disorder

This disorder is characterized by recurrent depressive episodes. The current episode is specified
as mild, moderate, severe, severe with psychotic symptoms.

Persistent Mood Disorder

(Cyclothymia and Dysthymia)

These disorders are characterized by persistent mood symptoms that last for more than 2 years.

Cyclothymia refers to a persistent instability in mood in which there are numerous periods of
mild elation or mild depression.

Dysthymia (neurotic/reactive depression) is a chronic, mild depressive state persisting for

months or years. It is more common in females with an average age of onset in late third decade.
An episode of major depression may sometimes become superimposed on an underlying
neurotic depression.
This is known as ‘double depression.’

Somatic or endogenous depression

Neurotic or reactive depression
(a) Caused by factors within the individual. Caused by stressful events

(b) Premorbid personality: cyclothymic or dysthymic. Premorbid personality: anxious, or obsessive.

(c) Early morning awakening (late insomnia). Difficulty in falling asleep (early insomnia).

(d) Patient feels more sad in the morning. Patient feels more sad in the evening.

(e) Feels better when alone. Feels better when in a group.

(f) Psychotic features like psychomotor retardation, Usually psychomotor agitation and no other
suicidal tendencies, delusions etc. are common. psychotic features.

(f) Relapses are common. Relapses are uncommon.

(g) ECT and antidepressants are used for management. Psychotherapy and antidepressants are used for
management.

(i) Insight is absent. Insight is present.