Mood disorders

ABAYNEH GIRMA(MD, PSYCHIATRIST)

DECEMBER 2017
 Definition of Terms
Mood is a person’s subjective emotional state that influences a person's
behavior and perception of the world
Affect is the objective appearance of mood
Mood disorders (according to DSM-V) involve a depression or elevation of
mood as the primary disturbance
Can have other abnormalities (psychosis, anxiety, etc.)

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Normal vs pathological mood
changes
Normal individuals experience mood changes all the time and do have
control over their moods and affects
Patients with mood disorders experience an abnormal range of moods
and lose some level of control over them.
Distress may be caused by the severity of their moods and their
resulting impairment in social and occupational functioning.

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Mood symptoms

sad irritable happy

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Mood Disorders Versus Mood
Episodes

Mood episodes are distinct periods of time in which some abnormal

mood is present. They are the building blocks of mood disorders.
Mood disorders are defined by their patterns of mood episodes.

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Different mood episodes
MANIA MIXED EPISODE

HYPOMANI
A

NORMAL
MOOD

DEPRESSION
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Types of Mood Episodes
Major depressive episode
Manic episode
Mixed episode
Hypomanic episode
The Main Mood Disorders
Major depressive disorder (MDD)
Dysthymic disorder
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder

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 PATIENTS WITH ELEVATED MOOD
PATIENTS WITH DEPRESSED MOOD DEMONSTRATE:-
EXPERIENCE

loss of energy and interest,

feelings of guilt, expansiveness,

difficulty in concentrating, flight of ideas,

loss of appetite, and decreased sleep, and

thoughts of death/suicide. grandiose ideas.

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Patients afflicted with only major depressive episodes are said
to have major depressive disorder or unipolar depression
Patients with both manic and depressive episodes or patients
with manic episodes alone are said to have bipolar disorder.
The terms unipolar mania and pure mania are sometimes used
for patients who are bipolar, but who do not have depressive
episodes.
Hypomania is an episode of manic symptoms that does not
meet the full (DSM-V) criteria for manic episode.
Cyclothymia and dysthymia are defined by DSM-V as disorders
that represent less severe forms of bipolar disorder and major
depression, respectively.

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 Major depressive disorder
DSM-V definition1/22/2018

5 of following symptoms, must include one of first two, occurred almost

every day for two weeks
1. Depressed mood
2. Loss interest in pleasurable activities
3. Appetite disturbance
4. Sleep disturbance
5. Agitation or retardation
6. Fatigue
7. Feelings of worthlessness or guilt
8. Difficulty concentrating or deciding
9. Recurrent thoughts of death

Exclude: substance use or medical conditions, or medication and

they must cause social or occupational impairment.
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SIG: E CAPS
10
 Course specifiers
MDD, Single episode
Absence of mania or hypomania
MDD, Recurrent
2 major depression episodes, separated by at least a 2 month period with
more or less normal functioning/mood
MDD, Chronic
Symptoms continuous for at least 2 years

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Other specifiers
Severity specifiers
◦ Mild
◦ Moderate
◦ Severe: with/without psychotic features

With melancholic features

With atypical features
With postpartum onset
With catatonic features
With seasonal pattern

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Epidemiology
Most common mood disorder
Point prevalence: 8%–10% females, 3%–5% males
Lifetime prevalence: 20%–25% females, 8%–13% males, female: male =
2
Prevalence in Ethiopia 9.1% (only 22% sought treatment) [Hailemariam,
2012]

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Aetiological factors
Bio-psycho-social model.
Heritablity: 2-3x increase in 1st degree relatives.
Psychosocial stressors may precipitate a depressive episode.
Neurotransmitters serotonine and norepinephrnie implicated as causing
symptoms of depression.

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Treatment of depression
Medications:
◦ Selective serotonin reuptake inhibitors (SSRIs)
◦ Tricyclic antidepressants (TCAs)
◦ Monoamine oxidase inhibitors (MAOIs)
◦ Other: venlafaxine, mirtazapine,, bupropion
Psychotherapy:
◦ Cognitive-behavioral therapy (CBT)
◦ Interpersonal therapy (IPT)
Other
◦ Electroconvulsive therapy (ECT)
◦ Light therapy – primarily for SAD
Phases of treatment: acute vs. maintenance
Additional treatments: anxiolytics, antipsychotics

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Course and Prognosis
Untreated depressive episodes are self-limiting but usually last from 6
to 13 months. Generally, episodes occur more frequently as the
disorder progresses.
Risk of relapse is 50% within the first 2 years after the first episode.
About 15% of patients eventually commit suicide.

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Antidepressant medications significantly reduce the length and severity of
symptoms.
They may be used prophylactically between major depressive episodes to
reduce the risk of subsequent episodes.
Approximately 75% of patients are treated successfully with medical therapy.

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Dysthymic disorder: DSM-V Criteria
A. Depressed/irritable mood
B. Presence of two of the following:
◦ Appetite disturbance
◦ Sleep disturbance
◦ Low energy/fatigue
◦ Poor concentration of difficulties making decision
◦ Feelings of hopelessness
C. Present for two year period (one year in children and adolescents)
D. No evidence of a Major Depressive Episode during the first two years (one
year for children)
E. No manic or hypomanic episode
F. No chronic psychotic disorder
G. Not related to organic factors

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Onset: subdivided into early onset (21 years) and late onset (21 years).
Point prevalence: 5%
Lifetime prevalence: 6.4% (8% female, 5% male)
Course:
◦ chronic by definition.
◦ Because chronic, often misdiagnosed as part of patient’s personality or missed.
◦ May respond to pharmacotherapy and other therapies, but because chronic,
prognosis may be guarded.

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Questions?

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Bipolar Disorders
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder

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 Manic Episode: DSM-IVTR Diagnostic
A.
Criteria
A distinct period of abnormally and persistently elevated, expansive, or
irritable mood
B. Mood disturbance plus three of the following symptoms (four if the mood
is only irritable):
◦ Inflated self esteem or grandiosity
◦ Decreased need for sleep
◦ More talkative than usual or pressure to keep talking
◦ Flight of ideas, or racing thoughts
◦ Distractibility
◦ Increase in goal directed activity
◦ Excessive involvement in pleasurable activities
C. Marked impairment
D. No psychosis
E. Not organic
DIG-FAST
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Mixed episode
The presence of alternating full blown manic and depressive episodes
within a 24 hr period.
Also called dysphoric mania
More common in women.

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Hypomania: Diagnostic
Criteria
All the criteria of a Manic episode except criterion C (marked
impairment)

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Differences Between Manic
and Hypomanic Episodes
Mania Hypomania
Lasts at least 7 days Lasts at least 4 days
Causes severe impairment in social No marked impairment in social or
or occupational functioning occupational functioning
May necessitate hospitalization to Does not require hospitalization
prevent harm to self or others
No psychotic features
May have psychotic features

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 Bipolar I disorder
Definition: Manic or Manic + MD Episodes
Epidemiology
◦ Equal gender distribution
◦ Point prevalence 0.5%–1%
◦ Lifetime prevalence as high as 1.6%

Course: recurrence is the rule; usually but not always, mostly returns to
healthy baseline between episodes.

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features predictive of bipolar Disorder:-
-early age of onset; before age 25

-psychotic depression;

-PPD esp. one with psychotic features;

-rapid onset and offset of dep.episodes of short duration (< 3 months);

-recurrent dep.(>5 episodes);

-atypical features;

-seasonality;

-Bipolar family hx.;

-trait mood lability;

-hypomania asso. with Antidepressants;

-repeated loss of efficacy of Antideressants after initial response;

-Depressive mood state (with pschomotor excit..,;

-irritability;

-hostility;

-tht-racing;and

-sexual arousal (during major depression)

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Aetiological factors
Biological, environmental, psychosocial, and genetic factors are all
important.
Genetics plays an important role, concordance rate among monozygotic
twins can be as high as 75% and rates for dizygotic twins are 5 to 25%.

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Bipolar II disorder
Definition: One or more hypomanic and MD episodes
No full-fledged manic or mixed episodes
Epidemiology
◦ Lifetime prevalence 0.5%
◦ Generally one or more major depressive episodes

Course:
◦ 10% progress to full bipolar I disorder
◦ Most patients improve between episodes

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Cyclothymia
Definition: periods of hypomanic and depressive symptoms not fulfilling
criteria for hypomanic and major depressive episodes
Epidemiology: lifetime prevalence 0.4%–1%

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Bipolar Disorder NOS
Bipolar features but not meeting criteria for a specific Bipolar Disorder

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 Management of bipolar disorder
Mood-stabilizing agents and antipsychotics
◦ lithium, divalproex, carbamazepine, lamotrigie, Olanzapine, risperidone

In bipolar depression, avoid antidepressants alone, as they may precipitate a

manic episode if prescribed in the absence of a mood stabilizer
Antidepressants, antipsychotics, and anxiolytics are mostly reserved for acute
exacerbations, but some patients require long term use of these agents

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Psychotherapy
Supportive psychotherapy, family therapy, group therapy (once the acute
manic episode has been controlled)
People with bipolar disorder need to have regular interpersonal and social
rhythm, drastic changes in sleep pattern can ppt a manic episode!

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Other mood disorders
Mood Disorder Due to a General Medical Condition
Depressive, elated, or irritable mood symptoms or anhedonia causing
significant distress or impairment
Symptoms physiologically due to a general medical condition
Not better accounted for by stress of having the medical condition
Not occurring exclusively during delirium

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Substance-Induced Mood
Disorder
Depressive, elated, or irritable mood symptoms or anhedonia causing
significant distress or impairment
Symptoms judged to be due to substance intoxication or withdrawal
Symptoms are not better accounted for by non-substance induced
mood disorder
Not occurring exclusively during delirium

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Mood Disorder NOS
Symptoms do not meet criteria for a specific mood disorder and difficult
to categorize as either depressive disorder NOS or bipolar disorder NOS

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 Summary
Mood disorders are characterized by sustained,
excessive and abnormal changes in mood that
result in impairment or distress.
Depression is the commonest mood disorder
which is potentially fatal.
Because either depressed mood or anhedonia
needs to be present in a Major Depressive
Episode, asking about both of these is a very
useful screening technique. Ask about the rest of
the symptoms of depression if one or both are
positive.

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Clinically, the “great divide” is the distinction between unipolar and
bipolar illnesses.
Remember to always ask about a past history of hypomanic/manic
symptoms to help rule out bipolar depression.
Mood disorders are treatable conditions with remarkable success.

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Questions?

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Famous people with mood
disorders
Those who have become eminent in philosophy, politics, poetry, and the
arts have all had tendencies toward melancholia.
—Aristotle, Problemata

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Famous people with mood
disorders

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