presentation by medical student~

2. Mood vs. Affect
• Mood – pervasive and sustained feeling tone
that is experienced internally and influences a
person’s behavior and perception of the world
• Affect – external expression of mood
Healthy person experience a wide range of
moods and have an equally large repertoire
of affective expressions; they feel in control
of their moods and affect

3. Mood Disorders
• Definition:
– a group of clinical conditions characterized by a loss of
that sense of control and a subjective experience of
great distress
• Categories
– Unipolar depression / Depressive Disorder
– Bipolar disorder I & II
– Hypomania
– Cyclothymia
– Dysthymia

4. Epidemiology
Incidence and prevalence
– MDD is common with lifetime prevalence of 5 to
12% for men and 10 to 25% for women.
– Bipolar I disorder is less common than MDD with a
lifetime incidence of about 1%

5. Sex Age Socio-cultural
• MD and manic • onset of bipolar • Depressive
episode is > is usually at the disorder >
common in age of 30 (also common in
woman can occur in single and
• bipolar I is equal children and divorced person.
in both men and older adults) • No correlation
women • MD occurs along with
• depressive entire stage socioeconomic
episodes is > spectrum status, races and
common in men religious group

6. ETIOLOGY
• Biological factors
– Biogenic amine
– Neuroendocrine regulation
– Sleep
– Kindling
– Genetic factors
• Psychosocial factors

7. Biologic
• Heterogenous dysregulation of biogenic amine, based on
findings of abnormal level of monoamine metabolites
HVA, 5-HIAA and MHPG in blood, urine and CSF of patient
• Serotonin depletion is associated with depression
Biogenic amine • Low levels of 5-HIAA are assoicated with violence and
suicide
• dopamine activity may be reduced in depression and
increased in mania
• Reflects disruption in biogenic amine input to the
hypothalamus
Neuroendocrine • Hyperactivity of the hypothalamic-pituatary-adrenal axis in
depression leads to increased cortisol secretion
regulation • In depression, there is decrease release of TSH, GH, FSH,
LH and testosterone
• Immune fx are decreased in both mania and depression

8. • In depression, abnormality include delayed sleep onset,
shortened rapid eye movement (REM) latency, increased length
Sleep of first REM episode and abnormal delta sleep
• Multiple awakenings and decreased total sleep time are
common in mania
• Sleep deprivation has been found to have anti-depressant effect
• Mood disorders may be a consequence of kindling in the
Kindling temporal lobes
• Kindling is a process by which repeated subthreshold
stimulation of a neuron generates an action potential
• This stimulation leads to a seizure at an organ level
• Both bipolar and depressive disorders run in families, but
evidence of heritability is higher in bipolar disorder
Genetic • Genetic association between the mood disorder, particularly
bipolar I disorder, and genetic marker have been reported for
chromosome 5, 11, and X

9. Psychosocial
Psychoanalytic
• Freud described internalized ambivalenbe toward a love object, which
can produce a pathological form of mourning if object is loss or
perceived loss
• The mourning takes the form of severe depression with feelings of guilt,
worthlessness and suicidal ideation
• Symbolic or real loss of love object is perceived as rejection
• Mania and elation are viewed as defense against underlying depression
Psychodynamic
• In depression, introjection of ambivalently viewed loss objects leads to
an inner sense of conflicts, guilt, rage, pain and loathing; a pathological
mourning becomes depression as ambivalent feelings meant for
introjected objects are directed at self
• In mania, feelings of inadequacy and worthlessness are converted by
means of denial, reaction formation and projection to grandiose
delusions

10. Cognitive
• Cognitive triad of Aaron Beck
• Negative self view
• Negative interpretation of experience
• Negative view of future
Learned Helplessness
• A theory that attributes depression to a person’s inability to control events
• Theory is derived from observed behaviour of animals experimentally given
unexpected random shocks which they cannot escape
Stressful life events
• Often precedes first episode of mood disorder
• Such events may cause permanent neuronal changes that predispose a
person to subsequent episode of a mood disorder
• Losing a parent before age 11 is the life event most associated with later
development of depression

11. MOOD EPISODE
– distinct periods of time in which - Defined by their patterns of
some abnormal mood is present. mood episodes
- They include depression, mania, - Includes Major Depressive
mixed-state, and hypomania Disorder (MDD), Bipolar I and II,
dsythymic disorder, and
cyclothymic disorder
MOOD
DISORDERS

12. (DSM-IV criteria)
MOOD EPISODES

13. MAJOR DEPRESSIVE EPISODE
A. ≥5 of the following sx , presented during the same 2-week
period and represent a change from previous functioning; at
least one of the sx is (1) depressed mood or (2) loss of
interest or pleasure
Depressed mood most of the
Markedly diminished interest
day, nearly everyday as
or pleasure in all or almost all Significant weight loss when
indicated by either subjective
activities most of the not dieting or weight gain
reports or observation made
days, nearly everyday
by others
Insomnia or hypersomnia
Psychomotor agitation or
nearly everyday Fatigue or loss of energy
retardation nearly everyday
Recurrent thoughts of death,
recurrent suicidal ideation
Feelings of worthlessness or Diminished ability to think or
without a specific plan, or a
excessive or inappropriate guilt concentrate, or indecisiveness,
suicide attempt or a specific
nearly everday nearly everyday
plan for commiting suicide

14. B. The symptoms does not meet criteria for a mixed
episode
C. The symptoms cause clinically significant distress or
impairment in social, occupational, or other
important area of functioning
D. The symptoms are not due to direct physiological
effect of substance or a general medical condition
E. The symptoms are not better accounted for by
bereavement, the symptoms persist for longer than 2
months or are characterized by marked functional
impairment, morbid preoccupation with
worthlessness, suicidal ideation , psychotic symptoms
or psychomotor retardation

15. Information from history
I. Depressed mood for a prolonged period of time
II. Anhedonia: inability to experience pleasure
III. Social withdrawal
IV. Lack of motivation, little tolerance of frustration
V. Vegetative signs
a. Loss of libido
b. Weight loss & anorexia or
c. Weight gain & hyperphagia
d. Low energy level
e. Abnormal menses
f. Early morning awakening
g. Diurnal variation: symptoms worse in the morning
h. Constipation
i. Dry mouth
j. headache

16. Information from MSE
• General appearance: psychomotor retardation or
agitation, poor eye contact, tearful, downcast,
inattentive to personal appearance
• Affect: constricted or labile
• Mood: depressed, irritable, frustrated, sad
• Speech: little or no spontaneity; monosyllabic; long
pauses; soft, low monotone
• Thought content: distractible, difficulty concentration,
complaints of poor memory, apparent diorientation
abstract thought may be impaired
• Insight and judgement: impaired because of cognitive
distortions ofpersonal worthlessness

17. MANIA (MANIC EPISODE)
Persistent elevated expansive mood
Criteria A :
-a distinct period of abnormally
and persistently elevated,
expansive, or irritable mood,
lasting at least 1 week

18. Criteria B
Inflated self
Decreased need
esteem or Talkative
for sleep
grandiosity
Excessive
involvement in
Increase in goal-
pleasurable Flight of ideas
directed activity
activity that
have a high risk
of negative
consequences
Distractibility
3≤ persisted symptoms / 4≤ if the mood is
only irritable

19. Criteria C :
• -The symptoms do not meet criteria for mixed
episode
Criteria D :
• -The mood disturbance is sufficiently severe to cause
marked impairment in occupational functioning or in
social activities or relationships with others
Criteria E :
• -The symptoms are not due to direct physiologic
effects of a substance, or general medical condition

20. Erratic and
disinhibited
behavior
Information Overextended in
Vegetative signs obtained activities and
from history responsibilities
Low frustration
tolerance with
irritability,
outbursts of
anger

21. MENTAL STATUS EXAMINATION
GENERAL • -psychomotor agitation, colourful clothing, excessive
APPEARANCE AND makeup, inattention to personal appearance, intrusive,
BEHAVIOUR entertaining, threatening, hyperexcited
AFFECT • -labile, intense ( may have rapid depressive shifts)
MOOD • -euphoric, irritable, demanding, flirtatious
• -pressured, loud, dramatic, exaggerated; may become
SPEECH : incoherent

22. • -flight of ideas, neologism, clang
THOUGHT PROCESS associations, circumstantiality, tangentiality
• -highly elevated self esteem, grandiose,
THOUGHT CONTENT delusions, less frequently hallucinations (mood
congruent themes of self worth and power)
• -highly distractible, difficulty concentrating,
COGNITION memory intact if not too distracted, generally
intact
INSIGHT & • -extremely impaired, total denial of illness and
JUDGEMENT inability to make any rational decisions.

23. Criteria A
• A distinct period of persistently elevated, expansive
or irritable mood, lasting throughout at least 4 days,
that is clearly different from the usual nondepressed
mood.

24. Criteria B
• 1) inflated self-esteem or grandiosity
• 2) decreased need for sleep
• 3) more talkative than usual or pressure to keep talking
• 4) flight of ideas or subjective experience that thoughts are
racing
• 5) distractibility
• 6) increase in goal-directed activity or psychomotor agitation
• 7) excessive involvement in pleasurable activities that have a
high potential for painful consequences (e.g., foolish
business investments)

25. Criteria C
• The episode is associated with an unequivocal change in functioning
that is uncharacteristic of the person when not symptomatic.
Criteria D
• The disturbance in mood and the change in functioning are
observable by others.
Criteria E
• The mood disturbance not severe enough to cause marked
impairment in social or occupational functioning, or to necessitate
hospitalization, and there are no psychotic features.
Criteria F
• The symptoms are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication or other treatment) or
a general medical condition (e.g., hyperthyroidism)

26. MANIA HYPOMANIA
• Last at least 7 days • Last at least 4 days
• Causes severe impairment • No marked impairment in
in social or occupational social or occupational
functioning functioning
• May necessitate • Does not require
hospitalization to prevent hospitalisation
harm to self or others • No psychotic features
• May have psychotic features

27. MIXED EPISODE
• Criteria are met for both manic episode and major
depressive episode
• These criteria must be present nearly everyday for at
least 1 week
• The symptoms of mania and depression occur
simultaneously.
• *example : tearfulness during a manic episode or racing
thoughts during a depressive episode.
• Mixed states are often the most problematic period
of mood disorders, increase susceptibility to substance
abuse, panic disorder, commission of violence, suicide
attempts, and other complications.
• A psychiatric emergency!!

28. 1. MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE
2. MAJOR DEPRESSIVE DISORDER, RECURRENT
DEPRESSIVE DISORDERS

29. Depressive disorders
• Can occur alone or as part of bipolar disorder
• Occurs alone = unipolar depression
• Symptoms must be present for at least 2 weeks
and represent a change from previous functioning
• > common in women than man 2:1
• Precipitating event occurs in at least 25% patients
Major
• Diurnal variation, with symptoms worse early in
Depressive the morning
disorder • Psychomotor retardation or agitation is present
• Associated with vegetative signs
• Mood congruent delusions and hallucination may
present
• May occur single episode or recurrent

30. Major Depressive Disorder, single
episode
• Presence of a single Major Depressive Episode
A
• The Major Depressive Episode is not better accounted for by
Schizoaffective Disorder and is not superimposed on
Schizophrenia, Schizophreniform Disorder, Delusional Disorder,
B or Psychotic Disorder Not Otherwise Specified
• There has never been a Manic episode, a Mixed episode or a
Hypomanic episode
C

31. Major Depressive Disorder, Recurrent
Presence of 2 or more Major Depressive Episodes
The Major Depressive Episode is not better accounted for by Schizoaffective
Disorder and is not superimposed on Schizophrenia, Schizophreniform
Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified
There has never been a Manic episode, a Mixed episode or a Hypomanic
episode

32. If the full criteria are CURRENTLY MET for a Major Depressive
Episode, specify its current clinical status and/or features
• Mild, Moderate, Severe without psychotic features/ severe with Psychotic features
• Chronic
• With catatonic features
• With melancholic features
• With atypical features
• With postpartum onset
If the full criteria are NOT CURRENTLY MET for a Major Depressive
Episode, specify the current clinical status of the Major Depressive
Disorder or features of the most recent episode
• In partial remission, In full remission
• Chronic
• With catatonic features
• With melancholic features
• With atypical features
• With postpartum onset

33. Other features
Melancholic Atypical Catatonic Psychotic
• 40-60% of • Characterized by • Features includes • 10-25% of
hospitalised patients hypersomnia, catalepsy, hospitalized
with major hyperphagia, reactive purposeless motor depression
depression moods, leaden activity, extreme • Characterized by the
• Characterized by paralysis, and negativism or presence of delusions
anhedonia, early hypersensitivity to mutism, bizarre and hallucinations
morning awakenings, interpersonal postures, echolalia
psychomotor rejection • Responsive to ECT
disturbance,
excessive guilt, and
anorexia

34. Bereavement
• Known as “simple grief”, is a rx to a major loss, usually
of a person
• Sx often last for 2 month and include crying
spells, problems sleeping, and trouble concentrating at
work
• should not include gross disorganization and suicidality
Normal Grief Depression
• Illusions are common • Hallucination and delusion is
• Suicidal thought are rare common
• Sx lasts for <2m • Suicidal thought may be present
• Mild cognitive disorder typically lasts • Sx usually persist >2m
<1 year • Mild cognitive disorder usually lasts
• Patient can be tx with mild for >1 y
benzodiazepine for sleep • Patient can be tx w anti-depressant,
mood stabilisers and ECT

35. Management of depressive disorders
Make diagnosis and assess severity
- Select anti-depressant treatment
- Assess need for hospital treatmentor multidisciplinary team involvement
- Coonsider precipitating/maintaining factors
Explain diagnosis, treatment plan, likely effects of treatment (benefit and
harms) to patient and relative
- Review after 7 days
- Assess side effects , provide explanation and reassurance
- Monitor every 7-14 days
- Assess response to treatment by 6 weeks (earlier if condition worsen)

36. Cont..
Assess response to treatment by 6 weeks
(earlier if condition worsen)
If better, If not better,
- Continue treatment - Review diagnosis
- Review need to modify precipitating and - Review adherence
maintaining factors
- Review dosage
When recovered If treatment adequate:
- Continue anti-depressant for 6 - Consider another anti-depressant
months or referral for specialist advice
- Consider long term treatment
for at least 2 years
If treatment inadequate
- increase and review once or twice
weekly

37. Treatment
Hospitalization Electroconvulsive Therapy (ECT)
• Indicated if patient is at risk of • Indicated if patient is unresponsive
suicide, homicide, or is unable to to pharmacotherapy, cannot
care for self tolerate pharmacotherapy or rapid
reduction of sx is required
• Safe and may be used alone or in
combination with
pharmacotherapy
Pharmacotherapy
• Anti-depressant medication
• Selective serotonin reuptake
inhibitors (SSRIs) – Venlafaxine,
Duloxetine, Bupropion
• Tricyclic antidepressant (TCA’s) -
• Monoamine Oxidase Inhibitors Psychotherapy
(MOIs) • Behavioral therapy, cognitive
• Adjunct medication therapy, supportive therapy,
• Stimulants (methylphenidate) – used psychoanalysis and family therapy
in certain patient.
• Anti-psychotic

38. DYSTHYMIC DISORDER

39. • Depressive neurosis
• Chronic, mild depression most of the time with
no discrete episode
• They rarely need hospitalization
• MDD tends to be episodic, while dysthymic
disorder is generally persistent
• Epidemiology –
– lifetime prevalence (6%)
– 2-3x > common in women
– Onset before age 25 in 50% of patients

40. • Insidious onset
• Occurs most often in persons with a history of
long term stress or sudden losses
• Often coexist with other psychiatric disorder
(substance abuse, personality disorder, OCD)
• Sx tends to be worse later in the day

41. DSM-IV Criteria
A. Depressed mood for most of the day, for more
days than not, as indicated either by subjective
account or observation by others, for at least 2
years. (In children and adolescent, mood can be
irritable and duration must be at least 1 year)
B. Presence, while depressed, of 2 (or more) of the
following:
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. low self esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness

42. C. During the 2-year period (1 year for children or
adoloscents) of the disturbance, the person has
never been without symptoms in Criteria A and
B for more than 2 months at a time
D. No Major Depressive Episode has been present
during the first 2 years of the disturbance (1
year for children and adolescents)
E. There has never been a Manic episode, a Mixed
episode or a Hypomanic episode and criteria
have never been met for Cyclothymic disorder

43. D. The disturbance does not occur exclusively
during the course of a chronic Psychotic
Disorder, such as Schizophrenia or Delusional
Disorder
E. The symptoms are not due to the direct
physiological effects of a substanceor a
general medical condition
F. The symptoms cause clinically significant
distress or impairment in social,
occupational, or other important functioning

44. • Course & prognosis
– 20% will develop major depression
– 20% will develop bipolar disorder
– >25% will have lifelong symptoms
• Treatment
– Cognitive therapy and insight-oriented psychotherapy
are most effective
– Anti-depressants are useful when used concurrently
with psychotherapy

45. BIPOLAR I DISORDER

46. Bipolar I Disorder
A syndrome in which a complete set of mania symptoms occurs
during the course of the disorder
The DSM-IV criteria for a manic episode requires the presence of a
distinct period of abnormal mood lasting at least 1 week
Manic episodes clearly precipitated by anti-depressant treatment
(eg pharmacotherapy, ECT) does not indicate bipolar I disorder
Divided into
• Single manic episode
• Recurrent

47. Bipolar II Disorder
• The diagnostic criteria for bipolar II disorders
is characterized by depressive episodes and
hypomanic episodes during the course of the
disorder, but the episodes of manic-like
symptoms does not quite meet the diagnostic
criteria for a full manic syndrome

48. OTHER TYPES OF BIPOLAR DISORDERS
1) RAPID-CYCLING
BIPOLAR
DISORDER :
can occur at any
is not in itself a diagnosis, time in the course
4 or more a course specifies for of bipolar disorder
depressive, manic bipolar disorder that and may come and
or mixed episode describes the pattern and go at varying points
within 12months. frequency of episodes over a lifetime
during a one year period. course of illness

49. 2)
HYPOMANIA :
-elevated mood
associated with -unlike with full
decreased need for mania, those with -less severe than
sleep, extremely hypomanic mania, with no
outgoing and symptoms are psychotic features
competitive, and often fully
have a great deal functioning
of energy.

50. TREATMENT OF BIPOLAR DISORDERS
PHARMACOTHERAPY :
• Lithium (mood stabilizer)
• -70% treated with lithium show partial
reduction of mania
• -mortality rate is 25% from acute
overdose, due to low therapeutic index

51. ATYPICAL
ANTICONVULSANTS ANTIPSYCHOTICS
(carbamazepine, valproic
(olanzapine,quetiapine,
acid)
ziprasidone)
• -act as mood stabilizers • -effective as both
• -especially useful for monotherapy and
rapid cycling bipolar adjunct therapy for
disorder and mixed acute mania
episodes

52. ANTIDEPRESSANTS
•-Are discouraged as monotherapy
due to concerns of activating
mania or hypomania
•-The addition of antidepressants as
adjunct therapy to mood stabilizers
are shown not to be effective

53. TREATMENT OF ACUTE MANIC EPISODES
-requires adjunctive use of potent sedative drugs
-example : clonazepam, lorazepam, haloperidol,
olanzapine and risperidone

54. • PSYCHOTHERAPY :
-supportive psychotherapy, family therapy, group
therapy (prolongs remission once the acute manic
episode has been controlled)
• ELECTROCONVULSIVE THERAPY
-works well in treatment of manic episodes
-especially effective for refractory or life
threatening acute mania or depression

55. CYCLOTHYMIC DISORDER
Less severe disorder
Alternating periods of HYPOMANIA and MODERATE DEPRESSION
Chronic and non psychotic
Symptoms must be present at least 2 years
Equally common in males and females
Insidious onset and occur in late adolescence or early adulthood.
Substance abuse is common
Recurrent mood swing

56. DSM-IV-TR CYCLOTHYMIC DISORDER
CRITERIA A : CRITERIA B : CRITERIA C:
• -at least 2 • -during the • -no major
years, presence above 2-year depressive
of numerous period, the episode, manic
periods with person has not episode, or
hypomanic been without mixed episode
symptoms and the symptoms has been
depressive for more than 2 present during
symptoms (in months at a the first 2 years
children, durati time of disturbance
on must be at
least a year)

57. Criteria D : Criteria E : Criteria F :
• -The symptoms in
criterion A are not
• -Symptoms • -The
better accounted are not due symptoms
for by to direct cause
SCHIZOAFFECTIVE
disorder, and are physiologic clinically
not superimposed effects of a significant
on SCHIZOPHRENIA,
SCHIZOPHRENIFOR
substance or distress or
M, DELUSIONAL general impairment
DISORDER, or medical in social,
PSYCHOTIC
DISORDER not condition. occupational
otherwise specified and other
areas.

58. TREATMENT
Antimanic agents used to treat bipolar disorders
• The use of antidepressants as monotherapy
typically worsens cyclothymia and can induce
mood switching
Therapy
• Cognitive behavioural therapy (CBT)
• Interpersonal psychotherapy (IT)
• Group therapy

59. MOOD DISORDER RESULTING FROM
GENERAL MEDICAL CONDITION

60. Myxedema madness Mad Hatter’s Syndrome
• Hypothyroidism •Chronic mercury
associated fatigability, intoxication produces
depression and suicidal manic (sometimes
impulses depressive) symptoms
• May mimic schizophrenia
with thought disorder,
delusion, hallucination,
paranoia and agitation
• > Common in women

61. Neurologic and Medical Causes of
Depressive and Manic Symptoms
Neurologic Endocrine Infectious and Miscellaneous
inflammatory medical
•CVA •Adrenal (Cushing’s, •AIDS •Cancer (pancreatic,
•Dementia Addison’s Dz) •Chronic fatigue n other GI)
•Epilepsy •Hyperaldosteronis syndrome •Cardiopulmonary
•Huntington’s dz m •Mononucleosis Dz
•Hydrocephalus •Menses-related •Peumonia •Porphyria
•Infections (HIV, •Parathyroid •Rheumatoid •Uremia
neurosyphillis) disorder arthritis •Vit Deficiency
•Migraine •Post-partum •Sjogren arteritis (B12, folate, niacin,
•Multiple sclerosis •Thyroid disorder •SLE thiamine)
•Narcolepsy •Temporal arthritis
•Neoplasm •Tuberculosis
•Parkinson Dz
•Wilson’s DZ