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Mood Disorders
Mood Disorders
Mood Disorders integrates two elements of DSM-V:
• Depression
• Bipolar.
They are combined because the predominant features have cross over /
similarities.
• Major depression (Depression)
• Dysthymia (Persistent Depressive Disorder)
• Bipolar I (mania),
• Bipolar II (Hypomania),
• Cyclothymia (Bipolar).
 MAJOR DEPRESSIVE DISORDER (MDD)

Over a two-week period = one episode

One or both of:

• Depressed mood (not simply sad, but empty)
• Loss of interest or pleasure: aka Anhedonia
(including complete loss of sex drive)
MAJOR DEPRESSIVE DISORDER (MDD)

Sleep Insomnia / Hypersomnia

Interest Anhedonia
Guilt Inappropriate Guilt
Energy Fatigue
Concentration
Appetite / Weight Weight Gain /Loss
Psychomotor Slow Thoughts, movement, speech
Suicidal Ideations If suicidal, it’s a Major Depressive Episode
MAJOR DEPRESSIVE DISORDER (MDD)

At least four of the following:

1. Significant weight loss or weight gain:
• Decrease or increase in appetite
• > 5% body weight in one month
2. Insomnia or hypersomnia every day:
• REM sleep increases in first half of sleep, has shorter
latency and increased time overall
• Decrease (maybe disappearance) of delta sleep
• Early morning waking
MAJOR DEPRESSIVE DISORDER (MDD)

3. Psychomotor agitation or retardation:

• Observable by others
4. Daily fatigue, energy loss
5. Daily feelings of worthlessness or inappropriate
guilt
6. Diminished ability to think or concentrate;
indecisiveness
7. Recurrent thoughts of death (for about 60%)
• Suicidal ideation
• Suicide attempt
• Specific plan for suicide
MAJOR DEPRESSIVE DISORDER (MDD)

• Symptoms cause clinically significant distress or social/

occupational impairment.
• Rule out substance abuse and other medical conditions.
• No history of mania or hypomania.
• Depression is more than feeling sad:
• A sense of nothingness.
• Represents a disorder when the mood "When it does
not go away.“
MAJOR DEPRESSIVE DISORDER (MDD)

• Lifetime prevalence: 2:1 (F:M)

• 10% to 25% for women
• 5% to 12% for men
• Two times more common in women
• 10% to 15% of these may really have bipolar disorder and are
misdiagnosed
• Mean age of onset is 20 to 30 years old
• Risk factors:
• Heritability index: 42%
• No close relationships (divorced)
• Parents depressed or alcoholic
• Parental loss prior to age 11
MAJOR DEPRESSIVE DISORDER (MDD)

Consequences:
• Increased overall mortality:
• Independent risk factor for coronary heart
disease
• Possible link to impaired immune function
• Suicide risk
• A leading cause of disability
• Dysfunction in social and occupational roles
MAJOR DEPRESSIVE DISORDER (MDD)

Biological findings for major depression

• High glucose metabolism in amygdala
• Smaller hippocampus greater atrophy if depressed
longer
• Abnormally high levels of glucocorticoids
• Decreases in neurotransmitters and their metabolites
MAJOR DEPRESSIVE DISORDER (MDD)

• Important specifications:
• Specify single episode or recurrent If recurrent and linked to seasons,
then Seasonal Pattern replaces old Seasonal Affective Disorder (SAD)
diagnosis:
• Subtype symptoms appear during the winter months, the time of least
natural light.
• "Atypical" symptoms:
• Increased sleep
• Increased appetite
• Decreased energy
• Disengagement from the world
• Caused by abnormal melatonin metabolism
PERSISTENT DEPRESSIVE DISORDER

• Replaces dysthymia and chronic major depression from

DSM-4
• Can be mild (old label: dysthymia) or
• Severe (old label: chronic major depression)
• Depressed mood for more days than not For at least >2
years (under age 18 for at least one year)
PERSISTENT DEPRESSIVE DISORDER

• At least two of the following:

• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy/fatigue
• Low self-esteem
• Poor concentration; difficulty with decisions
• Feelings of hopelessness
• Never without symptoms for >2 months
• No history of manic or hypomanic episodes
• Rule out hypothyroid, rule out suicide, and give SSRIs.
MANIA

DIGFASTER Mnemonic for Mania

Distractibility Distracted
Insomnia ↓ Need for Sleep
Grandiosity Self-Importance
Flight of Ideas Cannot Follow Conversations
Agitation, Activities Multiple Incomplete Projects
Sexual Exploits Spending Sprees, Promiscuity
Talkative Pressured Speech
Elevated mood
Racing thoughts
MANIC EPISODE

Elevated (or irritable) mood for >1 week. Three or more

of following (four if mood irritable):
• Grandiosity
• Decreased need for sleep
• Pressured speech
• Flight of ideas
• Racing thoughts
• Distractibility
• Increased goal-directed activity
• Excessive involvement in pleasurable activities with high risk
HYPOMANIC EPISODE
• Elevated or irritable mood lasting > 1 week
• Three or more of the following (four if mood irritable):
• Grandiosity
• Decreased need for sleep
• Pressured speech
• Flight of ideas,
• Racing thoughts
• Distractibility
• Increased goal-directed activity
• Excessive involvement in pleasurable activities with high risk
• Clear change in functioning but no marked impairment in social or
occupational functioning
BIPOLAR DISORDERS
Types of Bipolar Disorders
• Bipolar I:
• At least one manic episode May or may not have
major depression episode
• Bipolar II:
• At least one hypomanic episode,
• At least one major depressive episode
• Never had a manic episode

• If a patient requires hospitalization, has psychosis, or has had a

true manic episode, the patient must be diagnosed as Bipolar I,
not Bipolar II
CYCLOTHYMIC
Cyclothymic:
• Numerous periods of elevated mood
• But lacking sufficient symptoms to qualify for hypomanic
episode
• Numerous periods of depressed mood
• But lacking sufficient symptoms to qualify for major
depression episode
• Patients are more functional than those with either bipolar I or II
BIPOLAR DISORDERS
Some combination of mania plus depression
• Depressive phase of bipolar looks exactly like major depression
• Differentiation based on
• History
• Family history
• Lifetime prevalence of <1%
• Heritability index: 63%
• Males = females
• Mean age of onset: 30 years old
• Brain shows enlarged:
• Amygdala
• Cerebral ventricles
BIPOLAR DISORDERS

Course and prognosis:

• Chronic illness, typically with multiple episodes over
lifetime
• Major cause of distress and disability (depressive
episodes >> manic or hypomanic episodes)
• Chronic mood stabilizer therapy can reduce number
and severity of episodes over time
BUT
• Up to 15% of patients will kill themselves
Treatment of Bipolar
Disorder
• Established mood stabilizers are first-line treatment
throughout illness:
• Lithium
• Valproate
• Carbamazepine
• Olanzapine
• Lamotrigine
• Combination therapy often required
• Treatment should continue to prevent future episodes
Treatment Of Bipolar Disorder

Psychosocial treatment
Family therapy: increase medication
compliance, educate family about
symptoms, help family develop new coping
skills and communication styles
Bipolar Disorders:
Treatment of manic or mixed episode
Most common choices include:
• Lithium (may be preferable in euphoric episode)
• Valproate (may be preferable in mixed episode)
• Olanzapine
If psychosis is present, mood stabilizer often
combined with antipsychotic
Use adjunctive treatments as necessary:
• Benzodiazepines , sleep aids
ECT can be effective
Causes: Neurotransmitters
Depression
• Decreased norepinephrine
• Decreased serotonin
• Decreased dopamine
Mania-
• Increased serotonin
• Increased norepinephrine (NE)
DIFFERENTIAL DIAGNOSIS FOR
MOOD DISORDERS
• Other mood and anxiety disorders
• Mood disorder due to a general medical
condition
• Substance-induced mood disorder
• Adjustment disorder with depressed mood
• Psychotic disorders
• Premenstrual dysphoric disorder
MEDICAL CONDITIONS
• Thyroid abnormalities
• Cortisol abnormalities
• Parkinson’s disease
• Multiple sclerosis
• Epilepsy
• Brain tumor
• Cancer (e.g., pancreatic)
• Dementia
• Traumatic brain injury
• Autoimmune disorders
• Stroke
• Huntington’s disease
• Chronic infections
• Certain medications:
• Steroids
• Interferon
• Beta-blockers
• Isotretinoin (Accutane)
• Oral contraceptives
• Antidepressants
SUBSTANCE-INDUCED MOOD
DISORDER
• Alcohol: Depression
• Cocaine: Hypomania, Mania
• Amphetamines: Hypomania, Mania
• PCP, Ketamine: Hypomania, Mania
• Heroin: Depression
• Marijuana: Depression
• Mood symptoms with intoxication or withdrawal
• May take weeks-months to normalize mood
• Substance use highly comorbid in mood disorders
(bipolar I > bipolar II > MDD)
Case 1
CC: A 28-year-old male writer being seen for a routine annual physical
reports' recent irritability and insomnia.
HPI: He states that he has been extremely productive lately and that
his work has demonstrated the value of his enhanced alertness. Upon
further questioning, he reveals that he experiences these
hyperenergetic states episodically; they are often followed by
periods of malaise, apathy, loss of appetite, decreased ability to
concentrate, and hypersomnia (= MAJOR DEPRESSIVE EPISODE). He
has considered these fluctuations to be a normal consequence of his
work.
PE: Physical exam reveals a hyper alert but otherwise normal
appearing man.
Discussion
Bipolar II disorder should be considered in any case in
which hypomanic disorder is accompanied 6yrs prodrome
or postdrome depression that meets the criteria for
major depressive disorder. Hypomanic disorder is similar
to a manic episode except that mood disturbances are not
severe enough to cause marked impairment in social or
occupational functioning.
Case 2
• CC: A 16-year-old girl is brought by her mother to her
family physician because of mood fluctuations and poor
performance in school for the past year.
• HPI: She reports week-long episodes of tiredness and
generalized unhappiness over several years (=
DYSTHYMIA) followed by short periods of high energy
and euphoria. Her older brother is receiving treatment
for depression..
Discussion
Cyclothymic disorder entails a two-year history (one year
in children and adolescents) of numerous periods of
hypomanic symptoms preceded or followed by periods
marked by depressive symptoms that do not meet the
criteria for a major depressive episode. There is a 15%-
50% risk that the person will subsequently develop bipolar
I or II disorder.
Thank
You