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Mood Disorders

Major Depression And Bipolar Disorder

    Prevalence of Mood Disorders About 7.8% of the North American population report some type of mood disorder during their lifetime, and 3.7% over the

Family studies

indicate that the rate of mood disorders in relatives of probands (i.e., the person known to have the disorder) with mood disorders is generally two to three times greater than the rate in relatives of normal probands.

Twin studies

reveal that if one identical twin presents with a mood disorder, the other twin is 3 times more likely than a fraternal twin to have a mood disorder, particularly for bipolar disorder. Severe mood disorders may have a stronger genetic contribution than less severe disorders.

 • • • •

Biological dimensions: Neurobiological influences

Research indicates low levels of

serotonin

in the etiology of mood disorders but only in relation to other neurotransmitters, including norepinephrine and dopamine.

One of the functions of serotonin is to regulate systems involving norepinephrine and dopamine. The

permissive hypothesis

stipulates that when serotonin levels are low, other neurotransmitters are permitted to range more widely, become dysregulated, and contribute to mood irregularities.

Another theory of depression has implicated the endocrine system, particularly elevated levels of

cortisol

.



The study of the effects of various antidepressant drugs including MAO inhibitors,

tricyclics, and selective

serotonin reuptake (SSRIs)-has led to hypothesis about the role of the neurotransmitters in producing behaviors associated with depression.

 • •

.

Sleep disturbances

are a hallmark of most mood disorders. Depressed persons move into the period of

rapid eye movement sleep (REM)

more quickly than nondepressed persons and also show diminished slow wave sleep (i.e., the deepest and most restful part of sleep). This REM effect is reduced for persons who have depression related to recent life stress. REM activity is intense in depressed persons. Depriving depressed persons of sleep improves their depression.

• Persons with bipolar disorder and their children show increased sensitivity to light (i.e., greater suppression of melatonin when exposed to light at night). A relationship between seasonal affective disorder, sleep disturbance, and disturbance in biological rhythms has thus been proposed. • Different

alpha electroencephalogram (EEG)

values have been reported in the two hemispheres of brains of depressed persons. Depressed persons show greater right-side anterior activation of the cerebral hemispheres (i.e., left-side activation) than nondepressed persons. This type of brain function may be an indicator of a biological vulnerability for depression.

Depression

     

Depression can refer to a symptom or a disorder. The symptom of depressed mood does not necessarily mean a person has a depressive disorder.



Although some symptoms of depression occur frequently in people who “have the blues” but are nor clinically depressed, Depressive disorders are sometime referred to as unipolar disorder to differentiate these types of depression from that found in bipolar disorder. There are several categories of depressive disorder. Patients often describe the symptom of depression as one agonizing emotional pain and sometimes complain about unable to cry, a symptom that resolves as they improve. About two thirds of all depressed patients contemplate suicide, and 10 to 15 percent commit suicide.

     According to the

learned helplessness theory of depression

, people develop depression and anxiety when they assume they have no control over life stress. A depressive attributional style has the following three characteristics. First, the attribution is internal in that one believes negative events are one's fault. Second, the attribution is stable in that one believes that future negative events will be one's fault. Third, the attribution is global in that the person believes negative events will influence many life activities. Evidence is mixed as to whether learned helplessness is a cause or side effect of depression.

• • • These beliefs may comprise a

negative schema

, or an automatic and enduring cognitive bias/errors about aspects of life. :

Arbitrary inference

refers to the tendency of depressed persons to emphasize the negative rather than positive aspects of a situation.

Overgeneralization

refers to the tendency to take one negative consequence of some event and generalize to all related aspects of the situation.

Bipolar Disorder I & II Cyclothymia MDD –Severe with Psychotic features MDD- severe MDD-Moderate MDD Mild Dysthymia Adjustment d/o with Depressed Mood

Depressed Mood

 In every language, we often use the term depression to refer to normal feelings experiences after significant loss, such as the breakup of a relationship or the failure to attain a significant goal. Theses feelings are not classified as a depressive disorder by DSM-VI. Symptoms of grief over the death of a loved one also are not classified as a depression unless they continue for an unusually long period.

Mood Disorders

     .

Facts about Mood Disorders

Depressive disorder is relatively common. Bipolar disorders are much less common than depressive disorder. The overall rates of both depressive and bipolar disorders, but not their typical symptoms, seem to be affected by a variety of cultural, economic, and environmental factors.

Vulnerability factors for depression

 Genetic makeup, or heredity, is an important risk factor for both major depression and bipolar disorder.    Age is also a risk factor. Women are particularly a risk during young adulthood, while for men the risk is highest in early middle age. Gender is also a related risk. Twice as many women as men in the general population report a depressive disorder. Other risk factor are experiencing negative life events and lack of social support, particularly from close relationships. This support may be especially valuable if stressful life events have recently occurred.

Cont. Depression

   Almost all depressed patients (97 percent0 complain about reduced energy; they have difficulty finishing tasks, are impaired at school and work, and have less motivation to undertake new projects). About 80 percent of patients complain of trouble sleeping, especially, especially early awakening (I.e. terminal insomnia) and multiple awakenings at night, during which they ruminate about their problems. Many patients have decrease appetite and weight gain and sleep longer than usual.

Types of mood disorder Depressive Disorder or Unipolar

1.

Dysthymic disorder: 2.

1.

History of depressed mood a majority of the time.

Major depressive disorder: 1.

One or more major depressive episodes.

Bipolar Disorders

1.

2.

3.

Bipolar I disorder: One or more manic episodes, and usually one or more major depressive episodes.

Bipolar II disorder: At least one hypomanic episode and one or more major depressive episodes but no manic episode or cyclothymia.

Cyclothymic disorder: Numerous hypomanic episodes and numerous periods of depressive symptoms that do not meet criteria for major depressive episode.

Dysthymic Disorder



Dysthymic disorder shares many of the symptoms of major depressive, but unlike major depression, the symptoms in dysthymia tend to be milder and remain relatively unchanged over long periods of time, as much as 20 or 30 years.



Dysthymic disorder is defined by persistently depressed mood that continues for at least 2 years. During this time, the person cannot be symptom free for more than 2 months at a time. Many eventually experience a major depressive episode at some point.

  

a.

The mean age of onset for dysthymia is typically in the early 20s (i.e., late onset). The onset of dysthymia before age 21 (i.e., early onset) is associated with (a) greater chronicity, (b) relatively poor prognosis (i.e., response to treatment), and (c) stronger likelihood of the disorder running in the family.

b.

The median duration of dysthymic disorder is approximately 5 years in adults and 4 years in children. c.

Patients suffering from dysthymia have a higher likelihood of attempting suicide than those suffering from major depressive disorder.

DSM-IV-TR Diagnostic Criteria for Dysthymic Disorder A.depressed mood for mood for most of the day, for more days than not, as indicated either by subjective account or observation by other, for at least 2 years. Note: In adolescents, mood can be irritable and duration must be at least 1 year.

B. Presence, while depressed, of two (or more0 of the following: (1) (2) Poor appetite or over eating Insomnia or hypersomnia (3) (4) Low energy or fatigue Low self-esteem (5) (6) Poor concentration or difficulty making decisions Feelings of hopelessness C. During the 2-year period (1 yr. For children or adolescents) of the disturbance, the person has never been without symptoms in criteria A and criteria B for more than 2 months at a time.

Cont.DSM-IV-TR Diagnostic Criteria for Dysthymic d/o

D. No major depressive episode has been present during the

first 2 years of the disturbance (1 year for children and adolescent_ I.e. the disturbance is not better accounted for by chronic major depressive disorder, in partial remission. Note: there may have been previous major depressive episode provided there was full remission (no significant signs or symptoms for 2 months) before development of the dysthymic disorder. E. There has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria have never been met for cyclothymic disorder.

F. The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as schizophrenia or delusional disorder.

Cont.DSM-IV-TR Diagnostic Criteria for Dysthymic d/o

• • Age of onset is typically in the early 20s (i.e.,

late onset

). • • • • Onset of dysthymia before age 21 (i.e.,

early onset

) is associated with: Greater chronicity. Relatively poor prognosis (i.e., response to treatment). Stronger likelihood of the disorder running in the family. Greater prevalence of personality disorders.

Criteria for Major Depressive Episode A.

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

(1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad or empty) or observation made by other (e.g. appears tearful) Note: in children and adolescent can irritable mood.

(2) Markedly dimishid interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).

Cont.

criteria for major depressive episode

(3) Significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body weight in a month), or decrease or increase appetite nearly everyday. Note: in children, consider failure to make expected weight gains.

(4) Insomnia or hypersomnia nearly every day.

(5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) (6) Fatigue or loss of energy nearly everyday (7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-approach or guilt about being sick) (8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) ((9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

Recurrent Major depressive disorder

  When a person who has experience one major depressive episode develops the symptoms again at a later time, the diagnosis is changed to recurrent major depressive disorder.

DSM-IV-TR-Diagnostic criteria, p. 376 A.

As many as 85% of single-episode cases later have a second episode of major depression.

Dysthymia + MDD =

A.

B.

C.

Double depression

depressive episodes and dysthymic disorder. refers to both major Dysthymic disorder often develops first, and this condition is associated with severe psychopathology and a problematic future course. Double depression is quite common, with as many as 79% of persons with dysthymia reporting a major depressive episode at some point in their lives. Indeed, many do not recover after two years, and relapse rates are very high.

The bipolar disorders

 Is an illness involving episodes of mania and depression. Tends to be chronic. • Suicide is a common consequence.  Bipolar I – will experience episodes of mania and usually major depressive episodes as well. bipolar d/o has been found to occur with a higher frequency of creative people such as artist and poets than in the general population. Episodes of bipolar d/o tend to recur. The number of recurrence is greater in those who have a family history that include bipolar disorder.

Bipolar disorder

     Bipolar II Disorder is variant of bipolar disorder in which there has been no manic episode but at least one hypomanic period as well as a major depressive episode. A hypomanic episode refers to a period of manic behavior that is not extreme enough to greatly impair function. People who experience a hypomanic episode may not see it as pathological, although those around them may be concerned about the erratic behavior they see.

For the person affected, the feelings of elation and creativity and the driving energy characteristic of the hypomanic state can be positive forces.

DSM-IV-TR Diagnostic criteria, p.397

Manic/hypomanic& mixed episodes

A manic episode is a distinct period of abnormality and persistently elevated, expansive, o irritable mood lasting for at least 1 week, or less if a patient must be hospitalized. A hypomanic episode lasts at least 4 days and is similar to a manic episode except that is not severe enough to cause impairment in social or occupational functioning, and no psychotic features are present.

Both mania and hypomania are associated with inflated self-esteem, decrease need for sleep, distractibility, great physical and mental activity, and over involvement in pleasurable behavior

Cyclothymic disorder

 • • • is a more chronic version of bipolar disorder where manic and major depressive episodes are less severe. Such persons tend to remain in either a manic or depressive mood state for several years with very few periods of neutral (or euthymic) mood. For the diagnosis, the pattern must last for at least 2 years (1 year for children and adolescents). Such persons are also at increased risk for developing Bipolar I or II disorder.

Average age on onset is about 12 or 14 years. Cyclothymia tends to be chronic and lifelong. Most are female.

   

Suicide

Suicide is the eighth leading cause of death in the United States, although many unreported suicides occur.

Suicidal ideation suicidal attempt

than women. refers to serious contemplation about committing suicide, whereas refers to surviving an attempted suicide. The rate of suicide is increasing, especially among adolescents and the elderly. Males are 4-5 times more likely to commit suicide than females, although females are three times more likely to attempt suicide than men. This is explained by the fact that men choose more lethal methods of suicide

Risk factors

for suicide include the following: If a family member commits suicide, there is an increased risk that someone else in the family will also do so. Existence of a psychological disorder is related to suicide, as over 90% of people who kill themselves suffer from a psychological disorder. As many as 60% of suicides occur in persons suffering from a mood disorder.

• • • • Depression and suicide are still considered independent as suicide can occur without a mood disorder and not all persons with mood disorders try to kill themselves. Alcohol use and abuse are associated with 25% to 50% of suicides. Past suicide attempts is another strong risk factor in predicting subsequent suicide attempts. Most important risk factor for suicide is a severe, stressful event that is experienced as shameful or humiliating.

A Mnemonic Device for Remembering all the different sections of Psychological Disorders



D

epressed

P

atients

S

eem

A

nxious,

S

o

C

laim

P

sychiatrists" may be useful, as follows:   

D

epression and other mood disorders (major depression, bipolar disorder, dysthymia).

P

ersonality disorders (primarily borderline personality disorder).

S

ubstance abuse disorders.    

A

nxiety disorders (panic disorder with agoraphobia, obssessive-compulsive disorder).

S

omatization disorder, eating disorders (these two disorders are combined because both involve disorders of bodily perception).

C

ognitive disorders (dementia, delirium).

P

sychotic disorders (schizophrenia, delusional disorder and psychosis accompanying depression, substance abuse or dementia).

SIGECAPS': A Mnemonic for Symptoms of Major Depression and Dysthymia

 SIGECAPS=

SIG

+

Energy

+

CAPS

ules

S

leep disorder (either increased or decreased sleep)*

I

nterest deficit (anhedonia)

G

uilt (worthlessness,* hopelessness,* regret)

E

nergy deficit*

C

oncentration deficit*

A

ppetite disorder (either decreased or increased)*

P

sychomotor retardation or agitation

S

uicidality

SIGECAPS': A Mnemonic for Symptoms of Major Depression and Dysthymia

 NOTE: To meet the diagnosis of major depression, a patient must have four of the symptoms plus depressed mood or anhedonia, for at least two weeks. To meet the diagnosis of dysthymic disorder, a patient must have two of the six symptoms marked with an asterisk, plus depression, for at least two years

DIGFAST': Mnemonic for the Cardinal Symptoms of a Manic Episode Distractibility

  

I

ndiscretion (DSM-IV's "excessive involvement in pleasurable activities . . . ")

G

randiosity

F

light of ideas

A

ctivity increase

S

leep deficit (decreased need for sleep)

T

alkativeness (pressured speech) NOTE: A manic episode requires at least one week of elevated or irritable mood plus three of the seven symptoms described above DSM-IV=Diagnostic and Statistical Manual of Mental Disorders, 4th ed