Psychiatric Disorders: 1. Mood disorders

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Mood Disorders Dr. Mohamed H Al-Dabbas JBPsych , DPM, DCPsych Consultant Psychiatrist Private Clinic Amman – Jordan drmdabbas@hotmail.com Tel. +9626 4 601 602

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Definition: Mood Disorders Disorders characterised by mood disturbance (inappropriate depression or elation). Usually accompanied by abnormalities in thinking and perception arising out the mood disturbance. Classification: Bipolar affective disorder – Recurrent attacks of both mania and depression. (At least one manic/hypomanic episode required to make this diagnoses) Unipolar affective disorder – Recurrent attacks of depression only Mixed affective states – Cases where manic and depressive symptoms occur simultaneously.

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Epidemiology: Age – depressive disorders: Women : Highest prevalence rate between 35 & 45 years Men : prevalence rate increases with age Sex: Bipolar affective disorders : men = women. All depressive disorders : twice as common in women Social class: More common in social classes I, II, and V Marital Status: More common in divorced or separated Prevalence rate: 5% of the general population. Mood Disorders

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Major Depressive Disorder, Single Episode : diagnosed when person has one major depressive episode and has never had a manic or hypomanic episode Major Depressive Disorder, Recurrent : 2 or more major depressive episodes that are separated by a period of at least 2 months during which the individual is not depressed Dysthymic Disorder : shares symptoms with major depression, but symptoms are milder and remain relatively unchanged over long periods of time (at least 2 years) Grief / bereavement Unipolar Mood Disorders

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What is Depression? Abnormally depressed mood, loss of all interest and pleasure in activities, most of the day, nearly every day Prevalence: 5 - 12% for men 10 - 25% for women

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+10 Severe Depression Time (days) Mood Rating + 5 - 5 -10 Healthy Mild Depression 0 Mood High Mood Low Daily Symptoms of Depression

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10% treated with tranquilizers 20% treated with antidepressants 20% treated without medications 50% of patients never seek help Depressive Disorder

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Biological features of depression Sleep disturbances (EMW, initial insomnia, excessive) Change in appetite Change in weight Change is psychomotor activity Loss of energy and fatigue Loss of libido Change in bowel habit Clinical features of depressive disorders

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Appearance: Neglected dress and grooming Facial features Reduced rate of blinking Reduced gestural movements Downwards gaze, head inclined forwards Speech: Poverty of speech Hesitancy Mood: Subjectively and objectively depressed Cont. Clinical features of depressive disorders

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Thoughts: Morbid thoughts Concerned with the past, present and future Poverty of thought Suicide Psychotic features of depression: Delusions: Delusions of guilt, poverty, hypochondriacal Hallucinations Second person auditory hallucinations Cont. Clinical features of depressive disorders

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Cognition: Impaired attention and concentration Poor memory Other psychiatric symptoms: Phobic symptoms Obsessional symptoms Hysterical symptoms Hypochondriacal preoccupations Depersonalization Cont. Clinical features of depressive disorders

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At least 5 of the following, during the same 2-week period, must include either ( a ) or ( b ): Depressed mood Diminished interest or pleasure Significant weight loss or gain Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness Diminished ability to think or concentrate; indecisiveness Recurrent thoughts of death, suicidal attempt or plan DSM-IV Diagnostic Criteria for Major Depressive Episode

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Symptoms do not meet criteria for a mixed episode (i.e. meets criteria for both manic and depressive episode) Symptoms cause clinically significant distress or impairment of functioning. Symptoms are not due to the direct physiologic effects of substance or a general medical condition. Cont. DSM-IV Diagnostic Criteria for Major Depressive Episode

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In 1990 Depression was the 4 th leading cause of disability worldwide. Now Depression is the 2 nd leading cause of disability, after heart-related illness. The WHO estimates that by 2020, Depression will become the ‘single leading cause’ of disability worldwide.

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Alzheimer’s Cerebral Infarctions Dementia Huntington’s Multiple Sclerosis Parkinson’s disease Medical conditions associated with depression Cardiovascular Heart failure MI Inflammatory Lupus Irritable Bowel Malignancies Brain Pancreas GI Other Endocrine/Metabolic Hypo/Hyperthyroidism B12, Iron Deficiency Cushing’s Syndrome Hypocalcemia Diabetes Uremia AIDS/HIV Chr.Fatigue Sdr. Chronic Pain Neurological

Selected drugs associated with depression:

Selected drugs associated with depression Anticonvulsants Antihypertensives Antineoplastic agents Antiparkinsonian drugs Antipsychotics CNS Depressants Corticosteroids Digitalis preparation Histamine (H 2 )-antagonists Tuberculostatics

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Depression Mania Hypomania Mixed Episode Bipolar Mood Disorders Continued Symptomatic Recovering Recovered 8 Basic Clinical States New Subsyndromal

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Bipolar I Disorder : Alteration between full manic episodes & major depressive episode Bipolar II Disorder : Major depressive episodes alternate with hypomanic episode. Cyclothymic Disorder : More chronic/less severe version of bipolar disorder that lasts at least 2 years; involves hypomanic and depressive symptoms that don’t meet criteria for full major depressive or manic episode Rapid cycling: when a person has at least 4 manic or depressive episodes per 1 year Bipolar Mood Disorders

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Mania

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Mania: Biological features of mania Sleep disturbance Change in appetite Change in Wt. Change in psychomotor activity Increase drive in work and pleasure activities Increased energy without fatigue Hypersexuality- disinhibition Mood Disorders

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Mania: Appearance and behaviour Clothing - bright colors Untidy and disheveled appearance Overactivity  physical exhaustion Reckless behaviour Speech Pressure of speech = over talkativeness Mood Euphoria (infectious), or irritability and anger Brief episodes of depression Cont. Mood Disorders

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Thought Expansive ideas Pressure of thought Flight of ideas Psychotic features of mania Delusions: grandiosity, persecutory or of reference Hallucinations: 2 nd person auditory hallucination Insight Other psychiatric disorders: Schneiderian 1 st. rank of schiz.15% Mania: Cont. Mood Disorders

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The DSM-IV Diagnostic Criteria Manic episodes are characterized by the following symptoms: At least 1 week of profound mood disturbance is present, characterized by elation, irritability, or expansiveness Three or more of the following symptoms are present: Grandiosity Diminished need for sleep Excessive talking or pressured speech Racing thoughts or flight of ideas

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The DSM-IV Diagnostic Criteria for mania Clear evidence of distractibility Increased level of goal-focused activity at home, at work, or sexually Excessive pleasurable activities, often with painful consequences The mood disturbance is sufficient to cause impairment at work or danger to the patient or others. The mood is not the result of substance abuse or a medical condition. Cont.

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Etiology: Genetic Family studies : 1 st degree relatives  Bipol.=15%-20%  Unipol.=10%-15% Twin studies : Concord.rate  Bipol. : MZ=79%, DZ=19%  Unipol.: MZ=54%, DZ= 20% Biochemical theories Monoamine theories: Disturbance in CNS serotonin (5-HT) activity as an important factor. Other neurotransmitters implicated include norepinephrine (NE) and dopamine (DA). Endocrine abnormalities (  TSH,  cortisol) Electrolyte disturbances Mood Disorders

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Vigilance Motivation Norepinephrine Serotonin Anxiety Irritability Pain Cognitive function Mood Emotion Impulsivity Sex Appetite Aggression May need different antidepressant actions for different symptoms/system involved in depression Serotonin and Norepinephrine may relate to different depressive symptoms

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Psychological theories Maternal deprivation Relationships with parents Psychoanalytic theory: Freud: Feeling of love and hostility are present at the same time (ambivalence). Regression to the oral phase of psychosexual development Psychodynamic theory: Mania is a defense against depression Cont. Mood Disorders

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Cognitive theory: Four types of cognitive distortion in depression: Arbitrary inference: Drawing a specific conclusion Without sufficient evidences. Selective abstraction: Focus on a single details while ignoring others. Over-generalization: Forming conclusions based on too little and too narrow experience. Minimization and magnification: Under- or overvaluing the significance of a particular event. Separation Premorbid personality Etiology… Cont. Mood Disorders

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Life event studies Bereavement, separation in the six moths prior to the onset of depression Body built Patients of pyknic (stocky and rounded) build are particularly prone to affective disorders (Kretschmer) Etiology… Cont. Mood Disorders

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Management Physical Psychological Social Mood Disorders

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40 years ago The first antidepressants introduced First-generation antidepressants MARI = Monoamine re-uptake inhibitors e.g.: Imipramine Clomipramine Amitriptyline MAOI = Monoamine oxidase inhibitors e.g.: Tranylcypromine Phenelzine Second generation antidepressants e.g.: Maprotiline Mianserin 40 years ago The first antidepressants introduced 40 years ago The first antidepressants introduced Antidepressant Drugs

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Fluoxetine Paroxetine Sertraline Citalopram Fluvoxamine “Dual-Acting” Antidepressants: Venlafaxine Duloxetine Mirtazapine Bupropion R eversible I nhibition of M onoamines: Moclobemide S elective S erotonin R e-uptake I nhibitors : SSRI

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S T E P Ideal Drug Treatment afety olerability fficacy rice

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Management Cont… Lithium carbonate Antiepileptics used as mood stabilizers Antipsychotics Physical… Cont. Mood Disorders

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Electro-convulsive therapy (ECT): A brief electrical shock that induces a seizure; used therapeutically to alleviate severe depression when medication is not effective. Transcranial Magnetic Stimulation (TMS): Magnetic field causes a weak electrical field and electrical current within the brain. Has been useful in some cases of depression. Physiological Treatments

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Electro-Convulsive Therapy (ECT) Goal is to produce a seizure of at least 30 seconds duration Usually given q2 days for a total of 4-12 sessions

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Severe depression (psychotic or endogenous) Especially in the elderly Schizophrenia Catatonic type Mania Parkinson’s Disease In general, drug therapy is the primary treatment ECT is used if drugs fail or are not tolerated Indications of ECT

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Management… Psychological Psychotherapy: Supportive psychotherapy Individual dynamic psychotherapy Interpersonal psychotherapy Cognitive behavioral therapy (CBT) Social Rehousing Family support Mood Disorders

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Suicide among those with depressive disorders can exceed 15% Suicide is the second leading cause of death in adolescents Firearms r the most frequent method used in completed suicides Most people who commit suicide are depressed Depression can be a fatal disease 75% of people with depression can be successfully treated