- M.B.Ch.B, F.I.B.M.S(PSYCHIATRY)
2. Mood Disorder
- Mood change is the main psycho pathological feature.
- The abnormality is more intense and persistent than normal
variation in mood and often lead to problems in occupational and
social functioning.
3. Mood disorder
- mood disorderis the term given for a group of diagnoses in
theDSM IV TR disordersin ICD 10.
- English psychiatristHenry Maudsleyproposed an overarching
category ofaffective disorder . The term was then replaced bymood
disorder , as the latter term refers to the underlying or
longitudinal emotional state, whereas the former refers to the
external expression observed by others.
- Two groups of mood disorders are broadly recognized; the
division is based on whether the person has ever had
amanicorhypomanicepisode. Thus, there are depressive disorders, of
which the best known and most researched ismajor depressive
disordercommonly called clinical depression or major depression,
andbipolar disorder , formerly known as "manic depressive" and
described by intermittent periods of manic
anddepressedepisodes.
4. Classification of mood disorders
- DSM-IV-TR describes the followingepisodes :
- 1-Major Depressive Episode: lasts for 2 weeks
- 3-Hypomanic Episode: four days
- 4-Mixed Episode: one week
5. Classification of Mood Disorders contd
- Major Depressive Disorder
- Bipolar I Disorder= having a clinical course of one or more
manic episodes and, sometimes, major depressive episodes.
- Bipolar II Disorder: episodes of major depression and
hypomania
- Dysthymic Disorder : 2years
6.
- Epidemiology of mood disorders;
- 19.3% of the general population develops a mood disorder (14.7%
men, 23.9% women)
- 21.3% of women & 12.7%of men develop major depression.
- Average age of onset for bipolar illness is mid to late
twenties.
- Average age of onset of depression is mid thirties.
- Bipolar disorder occurs more in high socioeconomic groups.
- Mania and depression are manifested by symptoms involving the
effective, cognitive,Physical, social, and spiritual aspects of the
individual.
7. Major depressive disorder
- Common disorder, with a lifetime prevalence of about 15%
,perhaps as high as 25% in women.
- The incidence of major depressive disorder is also high in
primary care patients,in whom it approaches 10%, and in medical
inpatients , in whom it approaches 15%.
- An almost universal observation , is the two-fold greater
prevalence of the disorder in women than in men.
- The reasons for this difference have been hypothesized to
involve hormonal differences, the effect of childbirth, and
differing psychosocial stresses for women and for men.
8. Major depressive disorder
- The mean age of onset is about 40 years ; 50% of all patients
have an onset between age of 20-50 .
- Although uncommonly, MDD can also begin in childhood or in old
age.
- Some recent studies suggest that the incidence of MDD may be
increasing among people less than 20 years old.
- MDD occurs most often in people without close
interpersonalrelationships or in those who are divorced or
separated .
- No correlation have been found between socio-economic status
and MDD
9. Etiology
- Although the etiology of MDD is ambiguous and complex, it can
be divided into three main groups: biological ,genetic ,and
psychosocial.
- a. Biogenic amines :norepinephrine , and serotonin are the most
implicated.
- b. Other neuro-chemical factors: GABA ,and neuroactive peptides
particularly vasopressin, and the endogenous opiates.
- c. Neuro-endocrine regulation :adrenal , thyroid and growth
hormone.
- d. brain imaging abnormalities: still inconclusive.
- genetic data strongly indicate that significant genetic factor
is involved in the development of mood disorders. First degree
relatives of MDD are 1.5-2.5 times more likely to have bipolar I
disorder, and 2-3 times to have MDD. The concordance rate for MZ
twins is about 50% while in DZ twins is 10-25%.
10.
- 3. Psychosocial factors :
- a- life events and environmental stress:
- The life event most often associated with a person later
development of depression is losing a parent before the age of 11.
The environmental stressor most often associated with the onset of
an episode is the loss of a spouse.
- c- premorbid personality factors.
11. Signs and symptoms
- Two hallmarks of depression symptoms key to establishing a
diagnosis are:
- Loss of interest in normal daily activities You lose interest
in or pleasure from activities that you used to enjoy.
- Depressed mood. You feel sad, helpless or hopeless, and may
have crying spells.
12. Signs and Symptoms Contd
- Insomnia or Sleeping too muchWaking in the middle of the night
or early in the morning and not being able to get back to
sleep.
- 4. Impaired thinking or concentration
- Trouble concentrating or making decisions.
- Problems with memory.( difficulty with short term memory).
13. Signs and Symptoms Contd
- 6. Fatigue or slowing of body movements.
- Feel as tired in the morning.
- Have trouble getting out of bed.
- Feel like you're doing everything in slow motion, or you may
speak in a slow, monotonous tone.
14. Signs and Symptoms Contd
- Pessimism, poor self-esteem.
- Self-criticism8. Agitation
- You may seem restless, agitated, irritable and easily
annoyed.
- Difficulty controlling your temper.
15. Signs and Symptoms Contd
- 9 . Physical complaints, such as gastrointestinal problems
(indigestion, constipation or diarrhea), headache and backache.
Many people with depression also have symptoms of anxiety.
- Children, teens may react differently to depression.
- Kids may pretend to be sick, worry that a parent is going to
die, perform poorly in school, refuse to go to school, or exhibit
behavioral problems.
16. Signs and Symptoms Contd
- 10. Less interest in sex.
- A persistent negative view of yourself, your situation and the
future.thoughts of death, dying or suicide.
17. Differential diagnosis
- Endocrine disorders, infections, metabolic disorders ,
nutritional deficiencies, connective tissue diseases , drugs
(steroids , contraceptive pills, analgesics,..),etc.
- 2.Neurological disorders:brain tumors, infections, head injury
, epilepsy ,etc.
- 3.Mental disorders:anxiety disorders, bipolar disorder,
schizoaffective disorder, schizophrenia, substance abuse,Dementias
and pseudodementia
- 4 .Uncomplicated bereavement.
18.
- Diagnosticians recognize several subtypes or course
specifiers:
- Atypical depressionis characterized by mood reactivity
(paradoxical anhedonia) and positivity, significantweight gainor
increased appetite ("comfort eating"), excessive sleep or
somnolence ( hypersomnia ), a sensation of heaviness in limbs known
as leaden paralysis, and significant social impairment as a
consequence of hypersensitivity to perceivedinterpersonal rejection
.
19.
- Psychotic depressionis the term for a major depressive episode,
particularly of melancholic nature, where the patient experiences
psychotic symptoms such asdelusionsor, less commonly,hallucinations
. These are most commonly mood-congruent (content coincident with
depressive themes).
20.
- Catatonic depressionis a rare and severe form of major
depression involving disturbances of motor behavior and other
symptoms. Here the person is mute and almost stuporose, and either
immobile or exhibits purposeless or even bizarre movements.
Catatonic symptoms also occur inschizophrenia , amanic episode , or
be due toneuroleptic malignant syndrome .
- Postpartum depressionis listed as a course specifier in
DSM-IV-TR; it refers to the intense, sustained and sometimes
disabling depression experienced by women after giving birth.
Postpartum depression, which has incidence rate of 1015%, typically
sets in within three months oflabour , and lasts as long as three
months
21.
- Seasonal affective disorderis a specifier. Some people have a
seasonal pattern, with depressive episodes coming on in the autumn
or winter, and resolving in spring. The diagnosis is made if at
least two episodes have occurred in colder months with none at
other times over a two-year period or longer.
- Dysthymia , which is a chronic, milder mood disturbance where a
person reports a low mood almost daily over a span of at least two
years. The symptoms are not as severe as those for major
depression, although people with dysthymia are vulnerable to
secondary episodes of major depression (sometimes referred to
asdouble depression ).
22.
- Recurrent brief depression(RBD), distinguished from Major
Depressive Disorder primarily by differences in duration. People
with RBD have depressive episodes about once per month, with
individual episodes lasting less than two weeks and typically less
than 23 days. Diagnosis of RBD requires that the episodes occur
over the span of at least one year and, in female patients,
independently of themenstrual cycle . People with clinical
depression can develop RBD, and vice versa, and both illnesses have
similar risks.
- Minor depression , which refers to a depression that does not
meet full criteria for major depression but in which at least two
symptoms are present for two weeks.
23. Treatment
- Treatment have those galls :
- Ensure the safety of the patients
- Ensure complete diagnostic evaluation
- Ensure treatment of the immediate symptoms and the future of
the patients.
- For diagnostic evaluation, suicide and homicide risk,
dehydration and starvation, loss of social support.
24. It is necessary that every patient, whom we suspect to have
mood disorders,should be thoroughly assessed by careful and full
history and mental state examination. The notes of the social
worker and clinical psychologists should be studied too. The
necessary investigations to exclude other possible causes should be
done including full blood count, drug screening ,hormonal essays
including thyroid function tests, EEG, CT scan and if necessary
other neuroimaging techniques. 25. The line of management depends
on whether the disorder is acute or chronic, bipolar unipolar,
recurrent or a single episode.The choice of the treatment method
should be made by discussion with the patient, his relatives and
individual physician.The treatment methods include:
PsychologicalPharmacologicalPhysical 26. Treatment
- Cognitive therapy: was developed originally by Aaron Beck.
Focuses on cognitive distortions postulated to be present in MDD.
It works by helping patients identify and test negative cognitions;
develop alternative, flexible, and positive ways of thinking; and
rehearse new cognitive and behavioural responses.
- Interpersonal therapy: was developed by Gerald Klerman, focuses
on one or two of the patients current interpersonal problems. It is
based on two assumptions. First, current interpersonal problems are
likely tohave their roots in early dysfunctional relationships.
Personality factors need to be addressed and does not deal with
dynamics of the patients problems.
27. Treatment
- Psychosocial Therapy :cont
- Behaviour Therapy: is based on the hypothesis that maladaptive
behavioural patterns result in a persons receiving little positive
feedback and perhaps outright rejection from society.
- Psychoanalytically Oriented Therapy: the aims include
improvement in interpersonal trust, intimacy, coping mechanisms,
the capacity to grieve and the ability to experience a wide range
of emotions.
- Family Therapy: is indicated if the disorder jeopardizes a
patients marriage or family functioning or if the mood disorder is
promoted or maintained by the family situation
28. Treatment
- All current available antidepressants may take up to 3 to 4
weeks to exert significant therapeutic effects.
- Patient Education: patient should be educated about the
illness, benefit of drugs, side effects. Avoid providing patients
with large prescriptions due to the risk of suicide.
- Alternatives to drug therapy: ECT is used when a patient is
unresponsive to pharmacotherapy or the clinical situationis so
severe that the rapid improvement seen with ECT is needed.
Occasionally it is treatment of choice such as older depressed
patients.Phototherapy use in seasonal mood disorder.
29.
- Treatment should continue for at leas 6 months after
remission.
- Prophylactic treatment should be used in recurrent cases,
suicidal ideation and impaired psychosocial functioning
- Augmentation is used when treatment fails: Lithium,
Liothyrnine, L tryptophan.
30. In mild depression psychotherapyis the first line treatment
and pharmacological therapy is not recommended routinely as first
line therapy.In moderate to sever depressionwhen other treatments
for two weeks fail antidepressants should be first line
treatment.Indysthymiaantidepressants could be used as first line
treatment. 31. Tricyclic antidepressants:These drugs have many side
effects including anticholinergic effects, hypotension and
tachycardia and cardiac toxicity which makes them dangerous in
toxicity and overdoses. Tricyclic antidepressants should not be
used as first line treatment in mild to moderate depression.They
arerecommended for severely ill inpatients. 32. Specific serotonin
reuptake inhibitors : Including fluoxitine, paroxitine,
fluvoxamine, citalopram, sertraline, escitalopram. They are
recommended by NICE as first line pharmacological treatment of
depression because they have less side effects compared to
tricyclic antidepressants. They are relatively safer in overdoses.
However they might lead to gastric irritation, nausea, vomiting,
headache, increased anxiety and sexual dysfunction. 33. Specific
serotonin reuptake inhibitors : They cause decreased arousal, drive
and difficulty reaching orgasm. These side effects might lead to
noncompliance.The initial increased anxiety might lead to suicide.
34. Monoamine oxidase inhibitorsMAOIs : They are used for atypical
depression with reversed biological symptoms as increased appetite
and weight. It is recommended by NICE for those who do not respond
to SSRIs. The ireversible MAOIs have serious interaction with drugs
and food containing tyramine. 35. Monoamine oxidase inhibitorsMAOIs
: The reversible MAOIs as Meclobemide has less risk of interaction
but therapeutically less effective.Those drugs lead to postural
hypotension , overstimulation, sexual dysfunction, weight gain and
possibly addiction. 36. Serotonin and noradrenaline reuptake
inhibitors SNRIs: Venlafaxine and duloxetene.Venlafaxine is more
potent than SSRIs and recommendedby NICE for severely depressed
patients with monitoring the blood pressure.Doluxetene is not as
potent as Venlafaxine and it might lead to initial nausea.Both
drugs lead to nausea, hypertension, increased anxiety and sexual
dysfunction . 37. Other antidepressants: reboxetene: is selective
noradrenaline reuptake inhibitor. It has anticholinergic side
effects and sexual dysfunction. Neverthelss it is well tolerated
but evidence of its effectiveness is scarce.mirtazepine: is2
adrenoceptor antagonist. It cause sedation and weight gain.
Therefore it liked by patients with insomnia and disliked by obese
patients. 38. Other antidepressants: Mianserine is a tetracyclic
drug and is 2 adrenoceptor antagonist. It is less popular now
because of agranulocytosis. 39. Treatment resistant depression:
Augmetation therapy: Antidep and psychtherapy Antidep and atypical
antipsychotic Antidep and thyroid hormone 40. Mania 41.
Defination
- Mania is a Greek word meanmadness.
- Theterm used to describe a syndrome involving sustained and
pathological elevation of mood accompanied by other changes such as
disturbances of physical energy , sleep and appetite with psychotic
features.
42. Definition.. Contd
- Bipolar Affective Disorder (BAD)
- is an episodic illness , where periods of normal psychological
functioning are interrupted at intervals by periods of either mania
or depression.
43. Definition.. Contd
- Bipolar 1 disorderpreviously called Manic Depressive Illness
characterizes with episode of mania and depression or mania
only.
- Bipolar 2 disordercharacterized with depression and few
hypomania episode.
44. Features of a Manic Episode
- Extreme irritability & distractibility .
- Excessive "high" or euphoric feelings.
- Emotional liability between anger and euphoria.
45. Features of a Manic Episode
- Inflated self esteem and grandiosity.
- Reported self confident, capable and can do things better than
other.
- Unrealistic belief in one's own abilities and achievement
- Delusion of grandeur that they are famous, gift, and
extraordinary.
- Thought flow, flight of idea
- Poor judgment regarding personal, social, occupation and
activities.
46. Features of a Manic Episode
- Increased talkativeness, agitation, excessive involvement
in
- Wearing bright color, unusual dress & heavy makeup.
- Productivity, creativeinvolves in projectwith negatives
consequences.
- Decreased sleep, Increased sex drive
- Provocative or noxious behavior
47. Hypomania
- Is somewhat similar to mania, a less extreme mood state,
hypomania is defined as an elevated mood during which (1) no
hospitalization has ever been necessary and (2) no state of
delusional or other psychotic thinking ever coincided with the
elevated mood.
- Hypomania are not sever enough to cause impairment in social
and occupational function.
48.
- Hypomania may feel good to the person who experiences it. Thus,
even when family and friends learn to recognize the mood swings,
the individual often will deny that anything is wrong
- In the context of bipolar disorder, a mixed state is a
condition during which symptoms ofmaniaandclinical depressionoccur
simultaneously.
49. Treatment
- 1.Medications A. Mood stabilizer is the first line of treatment
for manic episodes. E.g. Lithium
- Mood regulators Anti-seizure medications, such as valproic acid
(Depakene),and lamotrigine (Lamictal).
- Antipsychotic medications such as risperidone (Risperdal),
olanzapine (Zyprexa) orSeroquel.
50. Treatment.Contd Mood Stabilize Adverse Effects Special
Concerns Lithium carbonate (Eskalith CR, Lithobid) Gastrointestinal
distress, lethargy or sedation, tremor, Hypothyroidism, diabetes
insipidus, renal diseasevalproic acid (Depakote, DepakeneSedation,
platelet dysfunction, liver disease, alopecia, weight gainElevated
liver enzymes or liver disease, drug-drug interactions, bone marrow
suppressionCarbamazepine (Tegretol)Suppressed WBC, dizziness,
drowsiness, rashes, liver toxicity (rarely)Drug-drug interactions,
bone marrow suppression 51. Treatments
- 3. Electroconvulsive therapy (ECT) ECT may also be considered
to treat acute episodes when medical conditions, including
pregnancy, make the use of medications too risky. ECT is a highly
effective treatment for severe depressive, manic, and/or mixed
episodes.
52.