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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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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.


Mood disorders

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.


Mood disorders

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.


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

- 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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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

- Maximum dose

- Duration: 8 weeks

- Drug: bupropion, MAOI, TCA

- If failed

Augment with lithium


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

Pharmacological causes of mania disorder )

- Amphetamines

- Cocaine

- Corticosteroids

- Cyclosporine

- Hallucinogens

- Methylphenidate

- Opiates and opioids

- Phencyclidine


Mood disorders

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


Mood disorders

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


Mood disorders

4- Cognitive and psychomotor disorder )

- Hyperactive

- Psychomotor agitation

- Distractability


Mood disorders

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


Mood disorders

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


Mood disorders

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


Mood disorders

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.


Mood disorders

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)


Mood disorders

- 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 )


Mood disorders

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


Mood disorders

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


Mood disorders

- 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


Mood disorders

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

-