Mood Disorders

Mood (Affective) disorders Department of psychology The first affiliated hospital of ZZU Huirong guo

Preface 





The affective disorders are so called because one of their main features is abnormality of mood Nowadays the term is usually restricted to disorder in which this mood is depression elation, but in the past some authors have included states of anxiety as well The symptom of depression is a component of many psychiatric symptoms and is also found commonly in certain physical diseases

Preface 

The central features of these syndromes are known as mood, pessimistic thinking, lack of enjoyment, reduced energy, and slowness. Of these, depressive mood is usually, but not invariably, the most prominent symptom



Similar considerations apply to states of elation. Elation can also occur as a symptom in several psychiatric syndromes, though it is less widely encountered than depression

Preface 

The central features are over-activity, selfimportant ideas, and elation. Of these, elation occurs least constantly, and irritability sometimes occurs instead. This syndrome is called mania

 Depression  Mania

Classification and Epidemiology



mania and depression as a single entity (Kraepelin ) unipolar depression unipolar mania



bipolar (Leonhard et al , 1962 )



Nowadays it is standard practice not to use the term unipolar mania, but to include all cases of mania in the bipolar group





Classification and Epidemiology 



Depressive symptoms are common ,point prevalence of between 13%-20% of the population , more frequent among women, the lower socioeconomic groups, and the divorced or separated Unipolar depressive disorders, the point prevalence is about 3% for men and 5%-9% for women, annual incidence vary from about 80 to 200 per 100000 among men and from 250 to 7800 per 100000 for women

Classification and Epidemiology 

bipolar disorder is less than 1 per cent and the annual incidence between 9 and 15 per 100000 for men and between 7 and 30 per 100 000 for women

 the ratio of women to men differ, but it is generally

agreed to lie between 1.3:1 and 2:1

Etiology  Genetic

causes  Biochemical causes   

The amine hypothesis Endocrine abnormalities Psychosocial factors

Pathogenesis Biological

Psychological

Depression Disorder

Social

Genetic causes 





Most family studies have shown that parents, siblings, and children of severely depressed patients have a morbid risk of 10%-15% for affective disorder, as against 1%-2% in the general population Twin studies suggest strongly that these high rates within families are largely due to genetic factors There are conflicting theories about the mode of inheritance because no simple genetic model fits the frequencies of cases observed among family members of different degrees of relationship to the proband

Biochemical causes  The 



amine hypothesis

this hypothesis is that depressive disorders are due to depletion, and mania to excessive provision, of a monoamine neurotransmitter at one or more sites in the brain More recent elaborations suggest a change in receptor sensitivity as well as a change in the turnover or level of the amines (noradrenaline, dopamine, and 5-hydroxytryptamine (5-HT) )

Biochemical causes 

The amine hypothesis



The hypothesis has been tested by observations of three kings of phenomena (1) antidepressant drugs, (2) the metabolism of neurotransmitters in patients with affective disorders, (3) the clinical effects of amine precursors and anatomists monoamine oxidase inhibitors (MAOI) tricyclic antidepressants These actions suggest that the concentration of one of these transmitters may be important in depressive disorders, but they do not indicate which one is involved

  

Biochemical causes  The  



amine hypothesis

More direct evidence comes from studies of postmortem brain Some investigators have reported lowered concentrations of 5-HT in the brain stem of depressed patients, but other investigators have not confirmed this No significant changes have been reported in concentrations of noradrenaline or dopamine in post-mortem brains of depressed patients

Biochemical causes  Endocrine 

abnormalities

These abnormalities are important in etiology for three reasons:

(1) some disorders of endocrine function are followed by depressive disorders more often than would be expected by chance , (2) endocrine abnormalities found in depressive disorder suggest that there may be a disorder of the hypothalamic centers controlling the endocrine system , (3) endocrine changes are regulated by hypothalamic mechanisms, which in turn are partly controlled by monoamine systems

Biochemical causes  Endocrine 



abnormalities

Much research effort has been concerned with abnormalities in the control of cortisol in depressive disorders Attempts have been made to relate these findings to changes in the neurotransmitters involved in the central control of ACTH secretion (5HT and acetylcholine may stimulate, and GABA and noradrenaline inhibit )

Biochemical causes  Endocrine 

abnormalities

The evidence reviewed above suggests that 5HT may be low rather than high depressive disorders, so increased 5HT could not account for the high output of cortisol

Biochemical causes  Psychosocial

factors



Depressive disorders often follow stressful events, However, several other possibilities must be discounted before it can be concluded that stressful events cause depressive disorders that succeed them



Firstly, the association might be coincidental



Secondly, the association might be non-specific; there might as many stressful events in the weeks preceding other kinds of illness

Biochemical causes  Psychosocial factors  Thirdly, it might be spurious; the patient might have regarded the events as stressful only in retrospect when seeking an explanation for his illness, or he might have experienced them as stressful only because he was already depressed at the time

 It is less certain whether mania is provoked by life events , mania was thought to arise entirely from endogenous causes in the past

Biochemical causes  Psychosocial 

factors

However, clinical experience suggests that a proportion of cases are precipitated, sometimes by events that have been expected to induce depression, for example bereavement

Manic episode and bipolar affective disorder 





Manic episode is characterized by a predominantly elevated, expansive, or irritable mood that presents as a prominent or persistent part of the illness The bipolar affective disorder is characterized by two or more episodes in which the patient’s mood and activity levels are significantly disturbed

This disturbance consists on some occasions of an elevation of mood and increased energy and activity and on others of a lowering of mood and decreased energy activity (depression)

Manic episode and bipolar affective disorder  Clinical

     

features :The central features of the

syndrome of mania are elevation of mood, increased activity, and self-important ideas The patient’s clothing overactive speech is often rapid and copious Sleep is often reduced Appetite is increased Sexual desires are increased and behavior may be uninhibited

Manic episode and bipolar affective disorder  Clinical    

features

Expansive ideas are common grandiose delusions Hallucinations also occur Insight is invariably impaired

Diagnosis 





Criteria for manic episode (DSM-IV, CCMD-3) are as follows: A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at 1 week During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

Diagnosis  







Inflated self-esteem or grandiosity Decreased need for sleep (feels rested after only 3 hours of sleep) More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing Distractibility (attention too easily drawn to unimportant or irrelevant external stimuli)

Diagnosis 



Increased in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation Excessive involvement in pleasurable activities that have a high potential for pain all consequences (engaging unrestrained buying sprees, sexual indiscretions, or foolish business investments)

Diagnosis 



The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or usual social activities or relationships with other, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. The symptoms are not due to the direct physiological effects of substance (a drug of abuse, a medication, or other treatment) or a general medical condition

Treatment & Prevention 





Treatment of bipolar disorder depends on the specific form of behavioral disorder at presentation Lithium carbonate is the treatment of choice for the acute manic state Complications are relatively, infrequent, but a transient "rebound" depression following resolution of a manic state is not uncommon

Treatment & Prevention 





The degree of psychomotor activation and the fragile structure of the treatment alliance in acute mania require that supplemental treatment with faster-acting neuroleptics be instituted in most cases Chronic treatment with neuroleptics is to be avoided, as the risk of tardive dyskinesia (TD) is increased in mood disorders the anticonvulsant drugs carbamazepine and valproate may be tried

Treatment & Prevention 





Some form of psychosocial intervention is almost always indicated in the treatment of bipolar disorder Some patients with bipolar disorder have infrequent recurrences, experience long symptoms-free intervals, and are able to lead productive lives Others may have a particularly malignant form of the syndrome or may exhibit pathological degrees of denial and lead turbulent lives calling for active psychosocial involvement by the therapist

Depressive Disorder Depressive syndrome can occur only or in a bipolar disorder. The clinical picture of depressive syndromes is so varied that they can not be described fully in a short space

Clinical Features    



The patient's appearance is characteristic Psychomotor retardation is frequent The mood of the patient is one of misery Agitation is state of restlessness that is experienced by the patient as inability to relax, and seen by an observer as restless activity Lack of interest and enjoyment is frequent, though not always complained of spontaneously

Clinical Features  





Reduced energy is characteristic The patient feels lethargic, finds everything an effort, and leaves tasks unfinished Sleep disturbance in depressive disorder is of several kinds Most characteristic is early morning waking, but delay in falling asleep and waking during the night also occurs

Clinical Features 

   



Weight loss often seems greater than can be accounted for merely by the patients’ lack of appetite Pessimistic thoughts are important symptoms concerned with the present The second group is concerned with the future The third group of thoughts is concerned with the past

The delusions of severe depressive disorders are concerned with the same themes as the non-delusional thinking of moderate depressive disorders (worthlessness, guilt, ill health, and poverty .Persecutory delusions )

Diagnosis   



DSM-IV CCMD-3 criteria for depression as follows: Major depressive episode Five (or more) of the following symptoms have been present during the same 2-week period and represent a change form previous functioning at least one of symptoms is either (1) depressed mood or (2) loss of interest or pleasure

Diagnosis 





The symptoms do not meet criteria for a mixed episode. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not due to the direct physiological effects of substance (a drug of abuse, a medication) or a general medical condition (hypothyroidism)

Diagnosis 

The symptoms are not better accounted for by bereavement, i.e. after the loss of a loved one, 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

Diagnosis 

Major depressive disorder, single episode



Presence of a single major depressive episode The major depressive episode is not better accounted for by schizoaffective disorder and is not supperimposed 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





Diagnosis 

Major depressive disorder, recurrent



Presence of two or more major depressive episodes; The major depressive episodes are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, shchizophlreniform disorder, delusional disorder, or psychotic disorder not otherwise specified. There has never been a manic episode, a mixed episode, or a hypomanic episode





Differential Diagnosis 

 

Depression occurs concomitantly with a number of different disease states :depression and dementia, especially in the elderly, may be confused. However, patients with dementia may develop major depression as well Schizophrenia present with behavioral and physiological changes identical to those observed in major depression

Treatment  

Biomedical therapies Psychosocial Therapies

Treatment :Biomedical therapies 



Antidepressant drugs have therapeutic effects in depressive illness .Two groups of drugs :one consists of the tricyclic antidepressants and related compounds ; The second consists of the monoamine oxidase inhibitors ; New generation antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) Drug selection should be based on the patient's general medical condition, the drug's side effects, and a personal or family history of therapeutic response to a specific agent

Treatment :Biomedical therapies 

 



Clear therapeutic benefit usually is noticed 1421days after starting treatment MAO inhibitors It is not always clear how long maintenance treatment should be continued after acute symptoms have subsided Patients with very severe depressions and prominent delusional features are relatively refractory to traditional antidepressant treatment

Treatment :Biomedical therapies 



The response often can be enhanced by addition of an antipsychotic agent. Electroconvulsive therapy should be considered in such cases and in cases of no delusional major depression resistant to drug therapy There are few contraindications to the use of electroconvulsive therapy

Treatment :Psychosocial 





 

therapies

improving social functioning following remission of acute symptoms the combination of psychotherapy and antidepressant medication is more effective than either used alone therapies focused on the depressed patient's interpersonal functioning and cognitive distortions appear to be the most productive Insight therapy Cognitive therapy (homework assignments )

Treatment :Psychosocial 

  

therapies

Family and spouse involvement should not be neglected in treatment planning education about the illness emotional support consideration of interpersonal issues

Some clinical cases A 27-year-old male graduate student  The patient was a surgeon referred by an internist A 34-year-old unmarried computer programmer was referred for evaluation of chronic depression.

summary It is difficult to conceive of an area in psychiatry in which the clinician’s attitude, knowledge, and skills are more severely tested than in the diagnosis and treatment of mood disorders.  As reviewed in this chapter, there is considerable evidence for a biological basis for most mood disorders. Data supporting this hypothesis have come from genetic, biochemical, psychopharmacological, and neuroendocrinological （神经内分泌） investigations, and the hope is that psychiatric diagnoses in this area will become a more objective press as these research efforts continue.

summary Although subgroups of mood disorders seem relatively distinct from one another as described, in clinical practice there is often considerable overlap between symptoms of different disorders as well as ambiguity about the class in which a given individual belongs. With the present state of knowledge, predictions about course of illness and response to treatment for patients with mood disorders remain as much an art as a science Use of the bio-psychosocial model in the understanding of mood disorders illustrates the awesome complexity of central nervous system regulation of affect but holds out promise of successful methods of treatment on many different levels

Thank you See you next time

Thank you See you next time