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Mood Disorders. - Major depressive Disorder - Bipolar Disorders - Dysthymia - Cyclothymia - Other mood disorders. I- Major depression. - Primary disturbance in mood - Syndromes rather than disease - Occur in cyclic fashion - Lost sense of control.

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Mood disorders
Mood Disorders

- Major depressive Disorder

- Bipolar Disorders

- Dysthymia

- Cyclothymia

- Other mood disorders


I major depression
I- Major depression

- Primary disturbance in mood

- Syndromes rather than disease

- Occur in cyclic fashion

- Lost sense of control


Dsm iv classification of mood disorders
DSM IV Classification of mood disorders

- Major depressive disorder ( unipolar depression ) = 2 weeks

- Hypomania = 4 days

- Bipolar I (Mania for 1 week, alternating episodes of Mania+ Mania, Mania+ MDD)

- Bipolar II( Hypomania+ MDD)

- Mixed episode = 1 week


Epidemiology

A-Prevalence

- Life time prevalence

MDD 10-15% in women Bipolar I = 0.4-1.6%

5-12% in men Bipolar II =0.5%

B- Sex

In MDD

-Women : Men = 2:1

Why? Child birth, hormonal differences, psychosocial stressors

In Bipolar

- Women = men

C- Mean age of onset

Bipolar I = 30 years MDD = 40 years


D- Marital Status

More in single, divorced, separated, poor interpersonal relations

E-Socioeconomic Status

No correlation for MDD, bipolar more in high SES

Depression more in rural areas


Etiology

A- Biological Factors

1- Biogenic amines ( levels in blood, urine,CSF)

Heterogeneous dysregulation of the biogenic amines

Low nor epinephrine, Serotonin in depression, Low dopamine in depression and high in mania

Others, GABA, Glutamate

2- Neuroendocrinal dysregulation

- Adrenal Axis ( Non suppression of dexamethasone suppression test)

- Thyroid Axis

Antithyroid antibodies, low thyroid hormones, development of rapid cycler


3- Sleep EEG abnormalities

  • Delayed sleep onset , short rapid eye movement( REM ) Latency, Increased duration of 1st REM period, abnormal Delta sleep

    4- Neuroimmune dysregulation

    5- Brain imaging studies

    Enlarged ventricles and small frontal lobes, Diminished cerebral blood flow


6- Genetic factors

Genetic evidence through family studies, adoption studies, twin studies.

Molecular biology: involvement of chromosome;5,11,18,X.

B- Psychosocial factors

- Life stressor commonly precede the occurrence of first MDD and bipolar disorder.

- Life events common in past history of patients : Loss of parent before the age of11 years, loss of spouse , unemployment.


C- Personality factors

- OCD, histrionic, borderline predict depression

- Dysthymia and cyclothymia predict bipolar

D- Psychodynamic factors

- In depression: damaged early attachment and traumatic separation in childhood

- In Mania: defense against underlying depression

E- Cognitive theory

Aaron Beck gave triad: depressed patient have negative view of self, world and future.


Major depression ( clinical picture)

1- Psychological symptoms

A- Depressed mood and sadness ( usually there is diurnal variation)

B- Loss of interest and lack of enjoyment (anhedonia)

C- Sense of emptiness, helplessness, hopelessness, worthlessness, pessimism, death wishes, suicidal thoughts, loss of self esteem, self blame and guilt

D- Psychotic symptoms in severe cases and are going with low mood

Delusions of guilt, nihilism, poverty, hypochondrias is and somatic delusions.

Hallucinations: auditory, visual.


2- Physiological symptoms ( somatic symptoms)

a- Diminished appetite

B- Weight loss

C- loss of sexual desire

D- Sleep disturbance: insomnia, early morning awakening, interrupted sleep

E- Pains ( Headache, back pain)

F- Digestive upsets and loss of appetite

Sometimes atypical symptoms ( increased appetite and hypersomnia


3- Behavioral symptoms

A- Negligence of self care

B- Social withdrawal, suicidal attempts

4- Motor and cognitive functions

A- Difficulty in attention and concentration

B- Slow thinking

C- Psychomotor retardation or agitation

D- Negative view of self, world and future

5- impaired social and occupational functioning


DSM IV criteria of Major Depressive episode

- Five or more symptoms present in the past 2 weeks with at least one either 1 or 2

1- Depressed mood and sadness

2- Loss of interest or pleasure

3- change in appetite

4- Insomnia or hypersomnia

5- Psychomotor retardation or agitation

6- Fatigue, loss of energy, or sexual problems

7-Feeling of worthlessness or excessive guilt

8- Decreased ability to think

9- Recurrent thoughts of death, suicidal ideas, or attempts


- Specify:

A- Mild, moderate, severe

B-With or without psychotic features (mood congruent/ incongruent)

C- With ;

1-Atypical features

- Mood reactivity, weight gain, hypersomnia, interpersonal rejection

2-Melancholic features

Severe anhedonia, weight loss, early morning awakening, guilt over trivial events, suicide


3- Seasonal pattern

Regularly occurring every winter or fall

4- Catatonic Features

Motoric immobility, excessive motor activity, negativism, mutism, posturing, stereotyped movement, echolalia, echopraxia

5- Postpartum

Within 4 weeks postpartum


Differential diagnosis

1-Medical disorders

-Substance induced mood ( abuse as sedatives , hypnotics, opoiods, phencyclidine,

or prescribed as contraceptive pills, corticosteroids, reserpine, cimetidine, alpha methyldopa, propranolol, amphetamines )

-Thyroid, diabetes, adrenal diseases, Rhematoid arthritis,SLE cancer lung,git

-AIDS

2-Neurological ( Parkinsonism, CVS, epilepsy, brain tumors)

3- Other mood disorders

4- Bereavement

5- Other mental disorders

- Personality disorders

- Schizophrenia

- Dementia


Management of MDD

A) Acute phase treatment = induction of remission( 4-6 weeks)

1- MDD (mild, moderate)

Pharmacotherapy +Psychotherapy

2- Severe without psychotic features

Pharmacotherapy+ Psychotherapy+ ECT

3- Severe with psychotic features

Pharmacotherapy +ECT + Antipsychotic

5- MDD and catatonic

Pharmacotherapy +ECT + Antipsychotic + BDZ

6- MDD in bipolar

Mood stabilizer + antidepressant


Most depressive illnesses can be managed in primary care setting, especially those with mild and moderate symptoms

Refer to psychiatrist if: suicidal risk is high,

Severe depression or psychotic depression, non response to treatment

I- Hospitalization

1- Suicide or homicide

2- To be sure of the diagnosis

3- Progressive symptoms and severe retardation

4- No social support

5- Catatonic

6- Psychotic depression

7- Refusal of treatment and food

8- Impaired insight


II- Electroconvulsive therapy (ECT ) setting, especially those with mild and moderate symptoms

1- Resistant pharmacotherapy

2- Condition need rapid improvement

3- Patient can't tolerate drugs

4- Catatonic

5- severe cases

6- suicidal symptoms


III- Pharmacotherapy setting, especially those with mild and moderate symptoms

A- Choice of drug

- Patient preference

- Family history

- Adverse effect

- Cost of the drug

- Clinician experience

- Pattern of symptoms

B- Strategies and dose

- Monotherapy ( TCA or SSRI )

Others ( MAOI, SNRI, Trazodone, Mirtazapine )

- Duration of each trial = 4-6 weeks

- If failed , check compliance, dose, drug level, and diagnosis

- Substitute, combine, augment with lithium, carbamazepine, L- thyroxine , or consider ECT


1- Tricyclic antidepressants (TCA ) setting, especially those with mild and moderate symptoms

- Amitryptyline( Tryptizole) = 75-150 mg

- Imipramine( Tofranil) = 75-150 mg

Side effects

- Cardio toxic

- Sedation, postural hypotension

- Weight gain

- Anti cholinergic

- Neurological

2- Selective Serotonin Reuptake Inhibitor (SSRI )

Escitalopram( Cipralex) = 20-60 mg

Fluoxetine( Prozac) 20-60 mg

Sertraline ( Lustral) = 50-200 mg

Fluvoxamine( Faverine) = 50-300 mg

Paroxetine( Seroxate) 20 mg


Side effects setting, especially those with mild and moderate symptoms

- GIT upset , Insomnia, agitation, headache, sexual

- Serotonin syndrome especially in combination

( Abdominal pain, fever, sweating, and flushing )

3- Others

- Tetracyclic antidepressant as Maprotiline (ludiomil) = 150-300 mg

- MAOI if atypical features ( used cautiously )

- SNRI as Venlafaxine ( Effexor)= 75-150 mg

- Serotonin modulator as Trazodone( Trettico) = 150-600 mg

- Bupropion ( wellabutrin) = 150 mg /day

- Nor epinephrine Serotonin modulator as Mirtazapine (Remeron) = 30 mg


IV- Psychotherapy setting, especially those with mild and moderate symptoms

A- Cognitive therapy

Goal; Alleviate episode and prevent recurrence

Technique: help patient to develop alternative ,flexible, and positive ways of thinking

B- Interpersonal therapy

Based on the fact that problems in interpersonal relations precipitate depressive illness

C- Behavioral therapy

D- Family therapy

E- patient education


B) Continuation Phase treatment setting, especially those with mild and moderate symptoms

- Aim : Prevent relapse

- Duration: 6-8 months

- Strategy: same treatment and same dose


C) Maintenance Phase setting, especially those with mild and moderate symptoms

- Aim: Prevent recurrence of symptoms

- Indications: Severe, psychotic depression, positive family history, serious, or recurrent

- Duration: If 2 episodes: interepisode duration

- If more than 2 episodes: 5 years or for life

- Strategy: Least effective dose


Ii dysthymia
II- Dysthymia setting, especially those with mild and moderate symptoms

Dysthymic disorder

Definition

Is a chronic disorder characterized by the presence of depressed mood that lasts most of the day and is present almost continuously

i.e Low grade depression, accentuation of depressive temperament

Epidemiology

- 5-6 % of all persons

- Onset: childhood and adolescence

- Sex = equal

- More in unmarried people, low income

- Coexist with MDD, medical illness, anxiety disorders especially panic, substance abuse and borderline personality disorder


Etiology setting, especially those with mild and moderate symptoms

As in depression

Clinical features

- 2 Years duration ( continuous )

Subjective > objective

- Depressed mood

- Habitual gloom, brooding, lack of joy, preoccupation with inadequacy

- No severe disturbance in appetite, libido, psychomotor retardation

DD

- MDD

- Minor depressive disorder

Episodic, periods of euthymic

- Double depression

MDD on top of dysthymia, Poorer prognosis


Treatment setting, especially those with mild and moderate symptoms

I- Hospitalization

Mostly not indicated except if marked affecting social life

II- Consider thyroid disease

III- Combine psychotherapy and pharmacotherapy

A- Cognitive therapy

i- Technique

Teach patient new way of thinking

ii- Replace faulty negative attitude about themselves, world and future


B- Behavioral therapy setting, especially those with mild and moderate symptoms

Goals:

Increase activity, provide pleasant experience, and teach patient how to relax

C- Interpersonal therapy

Improve interpersonal relations to improve self esteem

D- Family and group therapy


IV- Pharmacotherapy setting, especially those with mild and moderate symptoms

- Maximum dose

- Duration: 8 weeks

- Drug: bupropion, MAOI, TCA

- If failed

Augment with lithium


III) Other depressive disorders setting, especially those with mild and moderate symptoms

1- Depressive disorder not otherwise specified

A- Premenstrual dysphoric disorder

B- Minor depressive disorder

C- Recurrent brief depressive disorder

D-Post psychotic depressive disorder of schizophrenia

2- Mixed anxiety depressive disorder

3- Atypical depression

4- Secondary depressive disorder

- Mood disorder due to GMC

- Substance induced mood disorder


1-Premenstrual dysphoric disorder (Luteal phase dysphoric disorder )

Definition

Syndrome characterized by mood, behavioral, and physical symptoms occurring at specific time during the menstrual cycles and resolves in-between cycles

Epidemiology

40 % have symptoms

2-10 % have syndrome


Etiology disorder )

1- Hormonal changes

Abnormal high estrogen: progesterone ratio

2- Biogenic amines affected by changes in hormones

3- Societal and personal issues about menstruation and womanhood


Clinical picture disorder )

Presentation for 1 year

A- Mood symptoms

Depressed mood, anxiety, lability of affect, angry or irritable, increased interpersonal conflicts, sense of being out of control

B- Behavioral changes

Diminished usual activities, easy fatigability, change in sleep, appetite, and difficult in concentration

C- Physical symptoms

Breast tenderness, headache, joint pain , muscle pain, and sense of bloating ( wt gain )

Symptoms are severe to affect work, school, and social activities and relations


DD disorder )

- If no intercycle relief of symptoms, consider other mood disorder

If severe symptoms, exclude medical and surgical causes as endometriosis

Treatment

1- Supportive psychotherapy

2- Mild antidepressant esp. Fluoxetine (has long half life) , and bezodiazepines esp. alprazolam

3- Vitamins


2- Minor depressive disorder disorder )

2 weeks of mild symptoms than MDD

Treatment, mainly psychotherapy

3- Recurrent brief depressive disorder

Depressive disorder last from 2 days- 2 weeks

Recurrent / month for 12 months, not related to menses

Mostly +ve family history of mood disorder

4- Post psychotic depressive disorder

MDD in residual phase of schizophrenia


5- Secondary mood disorder disorder )

A- Mood disorder due to general medical condition (GMC)

- Persistence disturbance in mood ( depressed or elevated )

- Evidence ( history, examination, or lab of general medical condition )

- Absence of delirium

- Significant impairment


B- Substance induced mood disorder disorder )

- Persistence disturbance in mood ( depressed or elevated )

- Evidence ( history, examination, or lab of substance intake )

- Absence of delirium

- Significant impairment

Pharmacological causes of depression

- Cardiac and antihypertensive drugs

- Sedatives and hypnotics

- Steroids and hormones

- Stimulants and appetite suppressants

- Analgesics


Pharmacological causes of mania disorder )

- Amphetamines

- Cocaine

- Corticosteroids

- Cyclosporine

- Hallucinogens

- Methylphenidate

- Opiates and opioids

- Phencyclidine


II- Bipolar disorders disorder )

Episodes of both depression and mania (bipolar I) or hypomania (bipolar II) occur in separate episodes with a period of full or partial remission in between episodes

Clinical picture

1- psychological

Mood: elation, euphoria, and irritability

Thinking: racing thoughts, flights of ideas, mood related psychotic symptoms e.g delusions of grandiosity and power

Speech: hypertalkativness in a loud and rapid voice

Judgment: impaired


2- Behavioral disorder )

- Hyperactivity, restlessness

- Grandiose attitude and inflated self esteem

- Increased sociability, aggression and excitement

- Enthusiasm, multiple projects

- Sexual and social disinhibition

- Wearing bright colors, excessive cosmetics

- Overspending of money

3- Physiological

Full energy and lack of sense of exhaustion, decreased need for sleep, increased sexual activity, excessive eating


4- Cognitive and psychomotor disorder )

- Hyperactive

- Psychomotor agitation

- Distractability


DSM IV criteria of Manic episode disorder )

1- Elated, expansive, or irritable mood for 1 week

- Three or more symptoms present in the past 1 week

2- Inflated self esteem or grandiosity

3- Decreases need for sleep

4- Hyper talkative

5- Flights of ideas

6- Distractability

7- Involvement in pleasurable activity


8- Disinhibition disorder )

9- Impulsivity

10- Preoccupied by religious, sexual ideas or behaviors

- Specify:

A- mild, moderate, severe

B-With or without psychotic features (mood congruent/ incongruent)

C- With catatonic features, postpartum onset

D- If recurrent; rapid cycler or not


Hypomania disorder )

4 days of mild manic symptoms not affecting function, but observed by others

Mixed episode

The patient meet the criteria for depression and mania every day for 1 week

Bipolar with rapid cycler

4 episodes in 1 year


Treatment of Bipolar disorder disorder )

A) Acute phase = 4-6 weeks

I- Hospitalization ( as in MDD )

II- ECT

- Catatonic excitement

- Acute mania

III- Pharmacotherapy

Mood stabilizer + sedative + antipsychotic if with psychotic features

IV- Psychotherapy

Has no role, cognitive therapy may be used to prevent further attacks.


Approved mood stabilizers disorder )

-Typical features: Lithium carbonate ( Comcolit) 400 mg tab, 2 tablet/ day

divalproex( depakene chrono) 500 mg tab, 1-3 tablet/day, olanzapine( Zyprexa)

-Atypical features (Dysphoric mania, mixed episode, rapid cycler ): Carbamazepine ( Tegretol)200 mg tab. 3-6 tablet/day, or Divalproex

- Sedatives used: Benzodiazepines e.g Clonazepam( rivotril ), antipsychotics discontinued after 2-3 weeks

- Antipsychotics( Chlorpromazine, haloperidol)


- Trial = 4-6 weeks disorder )

If fail check drug, dose, diagnosis, compliance

Substitute, or combine lithium + Divalproate

- Drugs

A- Lithium

Dose = 800-1200 mg/day

Serum level = 0.8-1.2 meq /l

Side effects

Renal dysfunction, poluria, tremors, hypothyroidism, Hypokalemia and ECG changes, Ebstein anomaly, Seizures

B-Carbamazepine and Divalproex

C- New antiepileptic: Lamotrogine and Gabapentin ( add on )


B) Continuation Phase = 6 months disorder )

Strategy: Same dose of mood stabilizer, discontinue antipsychotic

C) Maintenance phase

If more than one episode, for 2 years


Cyclothymic disorder disorder )

Definition

Chronic ( 2 years ) fluctuating disturbance include periods of hypomania and depression in milder form than bipolar I, shorter duration than bipolar II

Epidemiology

Life time prevalence = 1 %

Coexist with border line personality disorder, and substance abuse

Clinical features

- Presentation : marital difficulties, instability of interpersonal relations


- Changes in mood are irregular, abrupt sometimes occur within hours

- Patient may be achiever if controlling his symptoms or may have professional and social difficulties

Differential diagnosis

- Substance abuse

- Mood disorder due to general medical condition

- Personality disorder

- Bipolar II disorder


Treatment within hours

I- Pharmacotherapy

- Mood stabilizer ( Lithium, carbamazepine, depakeme, clonazepam, gabapentin )

- Antidepressant used with cautious to avoid antidepressant induced hypomania

II- Psychotherapy

1- Individual therapy

Education to increase patient awareness to their condition and to help him to develop coping mechanism for their mood swings

2- Family and group therapy


Psychoeducation
Psychoeducation within hours

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