Mood Disorders. #1 cause of suicide #1 Disorder seen in outpatient.

Mood DisordersMood Disorders


#1 cause of suicide#1 cause of suicide #1 Disorder seen in outpatient#1 Disorder seen in outpatient


UnipolarUnipolar– Major DepressionMajor Depression– DysthymiaDysthymia– Depressive Disorder NOSDepressive Disorder NOS

BipolarBipolar– CyclothymiaCyclothymia– Bipolar IBipolar I– Bipolar IIBipolar II– Bipolar disorder NOSBipolar disorder NOS

Substance induced mood disorderSubstance induced mood disorder Mood disorder due to a medical conditionMood disorder due to a medical condition Mood Disorder NOSMood Disorder NOS

Major DepressionMajor Depression

Must have Must have – 1) Depressed Mood -dysphoria1) Depressed Mood -dysphoria

OrOr– 2) Loss of Interest or Pleasure in almost all activities-anhedonia2) Loss of Interest or Pleasure in almost all activities-anhedonia

Other symptoms (3-4)Other symptoms (3-4) Biological/Vegetative-Appetite, sleep, psychomotor, Biological/Vegetative-Appetite, sleep, psychomotor,

fatigue, libidofatigue, libido Psychological-concentration, neg thought, decision Psychological-concentration, neg thought, decision

making, guilt, low self esteem, hopeless, SImaking, guilt, low self esteem, hopeless, SI

Nearly every day for 2 weeksNearly every day for 2 weeks

Marked impairment in FunctioningMarked impairment in Functioning


Diagnosis is not made if:Diagnosis is not made if:– Symptoms meet criteria for Mixed episode Symptoms meet criteria for Mixed episode

(symptoms of mania and major depression (symptoms of mania and major depression occurring nearly every day for at least a week)occurring nearly every day for at least a week)

– No functional impairment existsNo functional impairment exists– Symptoms are direct physiological effects of a Symptoms are direct physiological effects of a

medical condition or substance inducedmedical condition or substance induced– Symptoms are better accounted for by Symptoms are better accounted for by

BereavementBereavement

Major Depression PresentationMajor Depression Presentation

Tearful, flat affectTearful, flat affect IrritabilityIrritability RuminationsRuminations Psychomotor changesPsychomotor changes FatigueFatigue Sense of Sense of

worthlessness/guiltworthlessness/guilt Worry over physical healthWorry over physical health Complaints of painComplaints of pain Suicidal IdeationsSuicidal Ideations Psychotic FeaturesPsychotic Features

Relational difficultiesRelational difficulties Poor/increased appetitePoor/increased appetite Sleep problemsSleep problems Impaired ability to think, Impaired ability to think,

concentrate, make concentrate, make decisions, recalldecisions, recall

Reduced libido and sexual Reduced libido and sexual functioningfunctioning

Substance abuseSubstance abuse Increased use of medical Increased use of medical

servicesservices

Cultural PresentationsCultural Presentations

May present more somaticallyMay present more somatically Latino/Mediterranean: Nerves, headachesLatino/Mediterranean: Nerves, headaches Chinese/Asian: weakness, tired, imbalanceChinese/Asian: weakness, tired, imbalance Middle Eastern: Problems of the “heart”Middle Eastern: Problems of the “heart” Hopi: Heart BrokenHopi: Heart Broken Nigeria and Ghana: “worms crawling all over the Nigeria and Ghana: “worms crawling all over the

head”head” Amish, Kenya and Rwanda-virtually unheard ofAmish, Kenya and Rwanda-virtually unheard of

Age Related PresentationsAge Related Presentations

Children: somatic, irritability, social Children: somatic, irritability, social withdrawalwithdrawal

Not common in children: psychomotor Not common in children: psychomotor retardation, hypersomnia and delusionsretardation, hypersomnia and delusions

Adolescents: Irritability, behavioral problemsAdolescents: Irritability, behavioral problems Elderly: disorientation, memory loss, Elderly: disorientation, memory loss,

distractibilitydistractibility


Twice as frequent in women than menTwice as frequent in women than men Occurs over the life spanOccurs over the life span Genetic links important to assessGenetic links important to assess

DysthymiaDysthymia

Does not meet criteria for Major DepressionDoes not meet criteria for Major Depression At least 2 years with no normal mood longer than At least 2 years with no normal mood longer than

2 months2 months No Manic, Mixed, Hypomanic, Cyclothymic No Manic, Mixed, Hypomanic, Cyclothymic

episode ever experiencedepisode ever experienced No psychotic symptomsNo psychotic symptoms Does not meet Major Depression Criteria during Does not meet Major Depression Criteria during

the first two yearsthe first two years Not due to medical or substanceNot due to medical or substance

DysthymiaDysthymia

Chronically depressed mood for 2 yrs, more Chronically depressed mood for 2 yrs, more days than notdays than not

An additional two symptoms: appetite, sleep An additional two symptoms: appetite, sleep disturbance, fatigue, low self-esteem, poor disturbance, fatigue, low self-esteem, poor concentration or hopelessnessconcentration or hopelessness

Some clinically significant distress or Some clinically significant distress or impairment in functioningimpairment in functioning

SpecifiesSpecifies

Early onset: Before 21 (More likely to Early onset: Before 21 (More likely to develop Major Depressive Disorder)develop Major Depressive Disorder)

Late Onset: Onset 21 yrs or laterLate Onset: Onset 21 yrs or later With Atypical Features: Reactive mood plus With Atypical Features: Reactive mood plus

2 (increased appetite, hypersomnia, 2 (increased appetite, hypersomnia, arms/legs feel heavy, rejection sensitivity arms/legs feel heavy, rejection sensitivity even when not depressed)even when not depressed)

Dysthymic PresentationDysthymic Presentation

Feelings of inadequacyFeelings of inadequacy General loss of interest or pleasureGeneral loss of interest or pleasure Social withdrawalSocial withdrawal Feelings of guilt of brooding over the pastFeelings of guilt of brooding over the past Irritability/angerIrritability/anger Decreased activityDecreased activity Vegetative symptoms are less commonVegetative symptoms are less common

DysthymiaDysthymia

Women 2-3 times more likely than menWomen 2-3 times more likely than men Equally in male and female childrenEqually in male and female children Early onset and chronic course Early onset and chronic course Genetically linked to Major depression and Genetically linked to Major depression and

DysthymiaDysthymia

CyclothymiaCyclothymia

Hypomania and DysphoriaHypomania and Dysphoria At least 2 yearsAt least 2 years No normal mood for over 2 months at a timeNo normal mood for over 2 months at a time Does not meet criteria for Major Depressive DisorderDoes not meet criteria for Major Depressive Disorder No Mania, Mixed or Major Depression during the first 2 No Mania, Mixed or Major Depression during the first 2

yearsyears Not due to psychosisNot due to psychosis Not due to substance or medicalNot due to substance or medical Clinically significant distress or impairment of functioningClinically significant distress or impairment of functioning


Chronic, fluctuating moodChronic, fluctuating mood Symptoms do not have to meet criteria for Symptoms do not have to meet criteria for

hypomania or dysthymia, but must hypomania or dysthymia, but must demonstrate symptoms similar to both demonstrate symptoms similar to both disordersdisorders


Onset: adolescents and early adulthoodOnset: adolescents and early adulthood Equally common in men and womenEqually common in men and women Chronic courseChronic course Genetic link to other mood disorders Genetic link to other mood disorders

(especially Bipolar I)(especially Bipolar I)

Bipolar IBipolar I

One or more Manic episode or mixed One or more Manic episode or mixed episodeepisode

Often they have Major Depression Episodes Often they have Major Depression Episodes as wellas well

Specifiers are the same as for Bipolar II and Specifiers are the same as for Bipolar II and will be covered in the next sectionwill be covered in the next section

Criteria needed for Manic DisorderCriteria needed for Manic Disorder

Distinct period (at least one week) of elevated, Distinct period (at least one week) of elevated, expansive or irritable moodexpansive or irritable mood

Three or more: grandiosity, sleep (3 hrs), Three or more: grandiosity, sleep (3 hrs), pressured speech, thoughts racing, distractibility, pressured speech, thoughts racing, distractibility, increased goal directed activity (planning and increased goal directed activity (planning and participating in several activities) or psychomotor participating in several activities) or psychomotor agitation, excessive involvement in high risk agitation, excessive involvement in high risk pleasurable activitiespleasurable activities

Symptoms do not meet criteria for Mixed disorderSymptoms do not meet criteria for Mixed disorder Not medical/substance inducedNot medical/substance induced Marked impairment in functioningMarked impairment in functioning

Manic PresentationManic Presentation

Do not recognize they are ill and resist treatmentDo not recognize they are ill and resist treatment Poor judgment and impulsivity combined with Poor judgment and impulsivity combined with

accelerated activity are likely to lead to behaviors accelerated activity are likely to lead to behaviors that will have neg. consequencesthat will have neg. consequences

After the episode there is usually regret for After the episode there is usually regret for behaviorsbehaviors

Mood is fun, irritable, angry, even depressed at Mood is fun, irritable, angry, even depressed at times. If the depression meets criteria for major times. If the depression meets criteria for major depression and occurs every day with mania-then depression and occurs every day with mania-then a mixed episode is diagnoseda mixed episode is diagnosed

Adolescents and ManiaAdolescents and Mania

Adolescents with mania are likely to have Adolescents with mania are likely to have psychotic features, school truancy and psychotic features, school truancy and failure, antisocial behaviors, and substance failure, antisocial behaviors, and substance abuse. They may have long standing abuse. They may have long standing behavioral problems before their first manic behavioral problems before their first manic episodeepisode

Course of ManiaCourse of Mania

Onset: early 20’s is average, but may begin Onset: early 20’s is average, but may begin at other timesat other times

Usually last a few weeks to several months Usually last a few weeks to several months and begin and end abruptlyand begin and end abruptly

Mixed episodeMixed episode

At least one week in which criteria for Mania and At least one week in which criteria for Mania and Major Depression are both metMajor Depression are both met

Presentation includes rapid altering of sadness, Presentation includes rapid altering of sadness, irritability, and euphoria. Individuals are often irritability, and euphoria. Individuals are often agitated, insomnic, have appetite changes, agitated, insomnic, have appetite changes, psychotic features (disorganized thinking and psychotic features (disorganized thinking and behavior) and suicidal ideationsbehavior) and suicidal ideations

Must cause marked impairment in functioning, Must cause marked impairment in functioning, have psychotic features, or require hospitalizationhave psychotic features, or require hospitalization

Not due to substances, Medical, of medicinesNot due to substances, Medical, of medicines

Bipolar IIBipolar II

Hypomania and Major DepressionHypomania and Major Depression No history of mania or mixed episodesNo history of mania or mixed episodes Not caused by substance or medicalNot caused by substance or medical Impairment in functioningImpairment in functioning

Hypomanic Episode Criteria needed Hypomanic Episode Criteria needed for Bipolar IIfor Bipolar II

Elevated, expansive, or irritable mood lasting 4 Elevated, expansive, or irritable mood lasting 4 daysdays

Three or more: grandiosity, sleep (3 hrs), Three or more: grandiosity, sleep (3 hrs), pressured speech, thoughts racing, distractibility, pressured speech, thoughts racing, distractibility, increased goal directed activity (planning and increased goal directed activity (planning and participating in several activities) or psychomotor participating in several activities) or psychomotor agitation, excessive involvement in high risk agitation, excessive involvement in high risk pleasurable activitiespleasurable activities

Mood and change noticeable by othersMood and change noticeable by others No severe functioning difficultiesNo severe functioning difficulties No medical/substance causeNo medical/substance cause

Specifiers for Bipolar I and IISpecifiers for Bipolar I and II

Hypomanic (current or most recent episode)Hypomanic (current or most recent episode) Depressed (current or most recent episode)Depressed (current or most recent episode)

– Current major depressive episodeCurrent major depressive episode Mild, moderate or severe without psychotic features Mild, moderate or severe without psychotic features

or with psychotic featuresor with psychotic features ChronicChronic With catatonic featuresWith catatonic features With melancholic featuresWith melancholic features With atypical featuresWith atypical features With postpartum onsetWith postpartum onset

Specifiers for Bipolar I and IISpecifiers for Bipolar I and II

If criteria for Major Depressive Disorder or If criteria for Major Depressive Disorder or Hypomanic Disorder are not metHypomanic Disorder are not met– In partial remission, In full remissionIn partial remission, In full remission– ChronicChronic– With Catatonic featuresWith Catatonic features– With Melancholic featuresWith Melancholic features– With Atypical featuresWith Atypical features– With postpartum onsetWith postpartum onset

Specifiers to indicate pattern or Specifiers to indicate pattern or frequency of episodes of Bipolar I frequency of episodes of Bipolar I

and IIand II Longitudinal Course Specifiers (with or Longitudinal Course Specifiers (with or

without interepisode recovery)without interepisode recovery) With Seasonal PatternWith Seasonal Pattern With Rapid CyclingWith Rapid Cycling

Additional ConsiderationsAdditional Considerations

If hypomanic episode occurs after age 40, If hypomanic episode occurs after age 40, strongly explore medical possibilitiesstrongly explore medical possibilities

Women with Bipolar II are more likely to Women with Bipolar II are more likely to have postpartum symptomshave postpartum symptoms

Genetic transmission Genetic transmission

Mood Disorder due to a General Mood Disorder due to a General Medical ConditionMedical Condition

Mood is the direct physiological effect of a medical Mood is the direct physiological effect of a medical conditioncondition

SubtypeSubtype– With depressive featuresWith depressive features– With major depressive-like episodeWith major depressive-like episode– With manic FeaturesWith manic Features– With mixed featuresWith mixed featuresImpairment in functioningImpairment in functioning

Note the type of medical condition on Axis I (due to …) and on Axis III Note the type of medical condition on Axis I (due to …) and on Axis III ICD-9-CM codeICD-9-CM code

GIVE HANDOUTGIVE HANDOUT

Substance Induced Mood DisorderSubstance Induced Mood Disorder

Direct physiological effect of a substanceDirect physiological effect of a substance Only made when symptoms exceed those Only made when symptoms exceed those

expected from intoxication or withdrawal from the expected from intoxication or withdrawal from the substance (otherwise dx substance intoxication or substance (otherwise dx substance intoxication or substance withdrawal)substance withdrawal)

Subtypes: w/ depressed features, w/ manic Subtypes: w/ depressed features, w/ manic features, w/ mixed featuresfeatures, w/ mixed features

With onset during intoxication, with onset during With onset during intoxication, with onset during withdrawalwithdrawal

GIVE HANDOUTGIVE HANDOUT

Mood Disorder NOSMood Disorder NOS

Mood Disorder does not meet any of the Mood Disorder does not meet any of the criteria discussed and there is not enough criteria discussed and there is not enough evidence to diagnose Bipolar NOS or evidence to diagnose Bipolar NOS or Depressive Disorder NOSDepressive Disorder NOS

Specifiers are noted with numbersSpecifiers are noted with numbers

.x1- mild-minimum symptoms met, capacity to function with .x1- mild-minimum symptoms met, capacity to function with extreme effortextreme effort

.x2-moderate-between mild and severe.x2-moderate-between mild and severe .x3-severe without psychotic features- severe impairment .x3-severe without psychotic features- severe impairment

and most symptomsand most symptoms .x4-severe with psychotic features- delusions or .x4-severe with psychotic features- delusions or

hallucinations (mood-congruent vs mood incongruent)hallucinations (mood-congruent vs mood incongruent) .x5- in partial remission: 1)reduced symptoms or 2) no .x5- in partial remission: 1)reduced symptoms or 2) no

symptoms for less than 2 monthssymptoms for less than 2 months .x6- in full remission: 2 months without symptoms.x6- in full remission: 2 months without symptoms .x0 unspecified.x0 unspecified

SpecifiersSpecifiers

Chronic- most recent type occurring continuously Chronic- most recent type occurring continuously for 2 yearsfor 2 years

Catatonic- motor immobility or stuporCatatonic- motor immobility or stupor– Excessive motor activity without purposeExcessive motor activity without purpose– Extreme negativism (motiveless resistence to instruction Extreme negativism (motiveless resistence to instruction

or rigid posturing) or mutismor rigid posturing) or mutism– Posturing, stereotyped movement and mannerismsPosturing, stereotyped movement and mannerisms– Echolalia (repetition of words-parrotlike) or echopraxia Echolalia (repetition of words-parrotlike) or echopraxia

(repetitve movements of another person)(repetitve movements of another person)

SpecifiersSpecifiers

Melancholic Features:Melancholic Features:– Loss of pleasure or lack of reactivity to positive Loss of pleasure or lack of reactivity to positive

events and events and – 3 or more symptoms: depression worse in am, 3 or more symptoms: depression worse in am,

distinctly depressed mood, early morning distinctly depressed mood, early morning awakening, marked psychomotor symptoms, awakening, marked psychomotor symptoms, significant weightloss, excessive guiltsignificant weightloss, excessive guilt

Atypical FeaturesAtypical Features

Mood ReactivityMood Reactivity Two or more:Two or more:

– Weight gain and increased appetiteWeight gain and increased appetite– HypersomniaHypersomnia– Leaden paralysisLeaden paralysis– Longstanding interpersonal sensitivity (not Longstanding interpersonal sensitivity (not

limited to mood disturbance) that results in limited to mood disturbance) that results in functional impairmentfunctional impairment

Not with Melancholic or catatonic featuresNot with Melancholic or catatonic features

Postpartum onsetPostpartum onset– Onset within 4 weeks postpartumOnset within 4 weeks postpartum

Recurrent episode specifiersRecurrent episode specifiers

-- With/without interepisode recovery-- With/without interepisode recovery

--Seasonal pattern--Seasonal pattern

--Rapid Cycling: At least four episodes in 12 --Rapid Cycling: At least four episodes in 12 months months

Differential DiagnosisDifferential Diagnosis

Uncomplicated BereavementUncomplicated Bereavement Acting out in adolescents: reduce acting out Acting out in adolescents: reduce acting out

(defense), depression may show itself(defense), depression may show itself Schizophrenia and schizodisorders: Mood Schizophrenia and schizodisorders: Mood

disorders can have psychotic symptomsdisorders can have psychotic symptoms Adjustment disorders with depressed moodAdjustment disorders with depressed mood

EtiologyEtiology

Family hx and genetics: depression, alcoholism, Family hx and genetics: depression, alcoholism, antisocialism, suicide attemptsantisocialism, suicide attempts

Neurological: serotonin, norepinephrine, dopamineNeurological: serotonin, norepinephrine, dopamine Psychosocial: loss of parent in 1Psychosocial: loss of parent in 1stst 5 years or father 5 years or father

from 10-14, low social support, abuse hx, from 10-14, low social support, abuse hx, predisposition & stress, personality factorspredisposition & stress, personality factors

Neuroendocrine: hormonal, adrenal (cortisol), Neuroendocrine: hormonal, adrenal (cortisol), thyroidthyroid

Sleep ProblemsSleep Problems

Medical TreatmentsMedical Treatments

ECTECT TCA’sTCA’s SSRIsSSRIs SNRIs and other atypical drugsSNRIs and other atypical drugs MAOIsMAOIs AntipsychoticsAntipsychotics LithiumLithium anticonvulsantsanticonvulsants

Psychological Treatments proven by Psychological Treatments proven by ResearchResearch

CBTCBT Interpersonal TherapyInterpersonal Therapy

Examples of What I doExamples of What I do

Suicide Assessment/Homicide AssessmentSuicide Assessment/Homicide Assessment Obtain blood workObtain blood work Close examination of symptom duration, frequency, onset, Close examination of symptom duration, frequency, onset,

family hx (genetics), vegetative symptoms, cognitive family hx (genetics), vegetative symptoms, cognitive interference, functional interference,and level of subjective interference, functional interference,and level of subjective distress to assess need for med evaluationdistress to assess need for med evaluation

Work with psychiatrist to ensure sleepWork with psychiatrist to ensure sleep Validate subjective experience and give sick roleValidate subjective experience and give sick role Explore triggers (ie interpersonal, stress, etc)Explore triggers (ie interpersonal, stress, etc) Explore strengths and encourage what has worked in the Explore strengths and encourage what has worked in the

pastpast

Examples of What I doExamples of What I do

Assess for cognitive and emotional regulation Assess for cognitive and emotional regulation skills. Build up areas of weakness to help in daily skills. Build up areas of weakness to help in daily functioning. Develop coping options for when functioning. Develop coping options for when episodes occurepisodes occur

Educate about disorder and med complianceEducate about disorder and med compliance Once daily functioning is more stable and begin Once daily functioning is more stable and begin

working on past issues to resolve and relearn working on past issues to resolve and relearn ways to interact with the environment and othersways to interact with the environment and others

Mood Disorders. #1 cause of suicide #1 Disorder seen in outpatient.

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