Mood disorders Department of Psychology P.G. Govt. College for Girls Sector-11, Chandigarh

Introduction Affect: A short lived emotional response to an idea or an event Mood: A sustained and pervasive response which colors the whole psychic life.

Introduction contd… Depression and mania are the opposite ends of same spectrum These are the two poles apart , thus generating the terms unipolar depression and bipolar disorder. It can also occur as a mixed state , hypomania or rapid cycling

Major depressive disorder Prevalence rate - DIAGNOSIS RATE Major depressive disorder Female :20 -25 % Male 7-12% Dysthymic disorder 6% Bipolar disorder - I 0.4-6% Bipolar disorder - II 0.5%

Mood [affective] disorders According to ICD –10 : Chapter F : F30-F39

ICD –10 Classification…….. F30 : Manic episode F30.0 Hypomania F30.1 Mania without psychotic symptoms F30.2 Mania with psychotic symptoms .20 With mood-congruent psychotic symptoms .21 With mood-incongruent psychotic symptoms F30.8 Other manic episodes F30.9 Manic episode, unspecified

ICD –10 Classification F31 : Bipolar affective disorder F31.0: Bipolar affective disorder, current episode hypomania F31.1 : Bipolar affective disorder, current episode mania without psychotic symptoms F31.2 : Bipolar affective disorder, current episode mania with psychotic symptoms .20 With mood-congruent psychotic symptoms .21 With mood-incongruent psychotic symptoms

ICD –10 Classification……. F31.3 : Bipolar affective disorder, current episode mild or moderate depression .30 Without somatic syndrome .31 With somatic syndrome F31.4: Bipolar affective disorder, current episode severe depression without psychotic symptoms

ICD –10 Classification……. F31.5 Bipolar affective disorder, current episode severe depression with psychotic symptoms .50 With mood-congruent psychotic symptoms .51 With mood-incongruent psychotic symptoms F31.6 Bipolar affective disorder, current episode mixed F31.7 Bipolar affective disorder, currently in remission F31.8 Other bipolar affective disorders F31.9 Bipolar affective disorder, unspecified

ICD –10 Classification…….. F32 : Depressive episode F32.0 : Mild depressive episode .00 Without somatic syndrome .01 With somatic syndrome F32.1 : Moderate depressive episode .10 Without somatic syndrome .11 With somatic syndrome

ICD –10 Classification…….. F32.2 : Severe depressive episode without psychotic symptoms F32.3: Severe depressive episode with psychotic symptoms .30 With mood-congruent psychotic symptoms .31 With mood-incongruent psychotic symptoms F32.8 : Other depressive episodes F32.9 :Depressive episode, unspecified

ICD –10 Classification……… F33 : Recurrent depressive disorder F33.0 :Recurrent depressive disorder, current episode mild .00 Without somatic syndrome .01 With somatic syndrome F33.1 : Recurrent depressive disorder, current episode moderate .10 Without somatic syndrome .11 With somatic syndrome

ICD –10 Classification F33.2 : Recurrent depressive disorder, current episode severe without psychotic symptoms F33.3 :Recurrent depressive disorder, current episode severe with psychotic symptoms .30 With mood-congruent psychotic symptoms .31 With mood-incongruent psychotic symptoms F33.4 :Recurrent depressive disorder, currently in remission F33.8 :Other recurrent depressive disorders F33.9 :Recurrent depressive disorder, unspecified

ICD –10 Classification F34 : Persistent mood [affective] disorders F34.0 Cyclothymia F34.1 Dysthymia F34.8 Other persistent mood [affective] disorders F34.9 Persistent mood [affective] disorder, unspecified

ICD –10 Classification F38 : Other mood [affective] disorders F38.0 Other single mood [affective] disorders .00 Mixed affective episode F38.1 Other recurrent mood [affective] disorders .10 Recurrent brief depressive disorder F38.8 Other specified mood [affective] disorders F39 : Unspecified mood [affective] disorder

Clinical features of depression Sad mood: Persistent and pervasive sadness of mood- Patient not responsive to external environment Lack of interest Diminished activity Weakness leading to fatigability Depressed mood Complete anhedonia: lack of pleasure

Clinical features depression…. Depressive ideations: Helplessness, hopelessness, worthlessness Guilt feelings Difficulty in concentration Indecisiveness Slowed thinking Lack of energy and initiative Suicidal ideations with nihilism

Clinical features depression…. Psychomotor activity Slowness in thinking and activity Depressive stupor

Clinical features depression…. Physical features: Multiple physical complaints (heaviness of head, vague body aches & paines) Easy fatigability

Clinical features Depression…. Biological features: Insomnia Reduced appetite Reduced weight Loss of libido

Clinical features depression….. Psychotic features: Nihilistic delusions Delusions of guilt Delusions of poverty

Clinical features for mania Elevated , expansive or irritable mood which may pass through following stages: Euphoria: Mild elevation of mood Elation: Moderate elevation Exaltation: Severe elevation Ectasy

Clinical features for mania… OVERACTIVITY RESTLESSNES MANIC EXCITEMENT

Clinical features for mania… Speech and thought: Over talkativeness Pressure of speech Flight of ideas Delusions of grandeur: Ability, Identity, Role

Clinical features for mania… Goal directed activity: Increased activity Over planning Poor judgment Other features: Decreased sleep Increased appetite

Bipolar mood disorder It is characterized by recurrent episodes of mania and depression in same patient at different times SUBTYPES : Bipolar I Bipolar II

Bipolar mood disorder………. Bipolar I Disorder One or more manic episodes usually alternating with major depressive episodes Manic episodes – periods of abnormally and persistently elevated, expansive or irritable mood Bipolar II Disorder Major depressive episode and at least one hypomanic episode No manic episode

Bipolar mood disorder……….. The current episode can be specified as : Hypomania Mania without psychotic symptoms Mania with psychotic symptoms Mild or moderate depression Mixed or remission Severe depression with/ without psychotic symptoms

Recurrent depressive disorder It is characterized by recurrent depressive episodes: The current episode can be specified as : Mild Depression Moderate Depression Severe depression with / without psychotic symptoms

Persistent mood disorder It is characterized by persistent mood symptoms for more than 2 years : Dysthymia Cyclothymia

Dysthymia…….. Milder form of depressive illness Criteria Symptoms less severe but chronic Criteria Depressed or irritable mood most of the day, occurring more days than not for at least 2 years No more than 2 months in which s/s not present No manic or depressive episode Important because of chronic nature

Cyclothymia…… Resembles Bipolar I Disorder with less severe symptoms Repeated episodes of nonpsychotic depression and hypomania for at least 2 years Diagnosed only if a major depressive or manic episode has never been present

Other mood disorders The full clinical picture of ,mania and depression are present either: at same time intermixed or alternates rapidly with each other without a normal intervening period of euthymia

Course and prognosis BMD has early age of onset ( 3rd decade ) than RDD UNIPOLAR DEPRESSION is common in 3rd decade and 5th to 6th decade Average manic episode lasts for 3-4 months Average depressive episode lasts for 4–6 months Nearly 40% of depressives with episodic course improve in 3 months 60% of which may last for two or more years improve in 6 months 80% improve in one year 15-20 % develop a chronic course

Prognosis Good prognostic factors: Acute onset Typical clinical features Severe depression Well adjusted pre morbid personality Good response to treatment

Prognosis Poor prognostic factors: Co-morbid medical disorder, PD Double depression Chronic stress Unfavorable environment Mood incongruent psychotic features Hypochondriacal features Poor drug compliance

Etiology: 1. Genetic Hypothesis: life time risk for First degree relatives of Bipolar Mood Disorder is 25% Recurrent Depressive Disorder is 20% Children of one parent with Bipolar Mood Disorder is 27% Both parents with Bipolar Mood Disorder is 74%

Etiology contd……. 2. Biochemical theories: The monoamine hypothesis Postsynaptic alteration in receptors number and function Decrease in serotonergic function

Etiology contd……. 3. Brain Imaging (MRI, PET scan): Ventricular dilatation Changes in blood flow and metabolism

Etiology contd……. 4. Learned Helplessness: Seligman Experiment of dogs

Predisposing Factors Genetic Physiological Endocrine system (HPA axis and HPT axis) Cortisol (hyper-secretion) Neurotransmission Dysregulation hypothesis Abnormal transmission of serotonin Biological rhythms Periodic variations in physiological and psychological functions

Predisposing Factors Psychological Psychodynamic factors Anger turned inward Learned helplessness Passivity, negative expectations, feelings of helplessness, hopelessness, and powerlessness Cognitive Errors in thinking and unrealistic attitudes Errors precede mood changes

Precipitating Stressors Stress due to major or minor life events Loss of attachment Disruptions of patterns Loss of self-esteem Interpersonal discord Physical conditions Impairment of social role performance Certain events more predictive than others Abuse, multiple family disadvantages

Management/ Treatment Acute phase treatment: To achieve euthymia and thereby current episode to conclusion Continuation phase treatment: Maintainance phase treatment: To prevent the future episodes

Acute phase treatment Choose the venue for treatment Select the appropriate mood stabilizer: Medicines Manage the agitation and psychosis Optimize the patient’s sleep

Mood stabilizers Lithium Valporate Carbamazepine Atypical antipsychotics

Management of agitation and psychosis Benzodiazapines Anti psychotics Optimizing sleep: Bedtime dose of benzodiazepine or anti psychotic

Maintainance phase It is indicated in following cases: Partial response to acute treatment Poor symptom control during continuation treatment More than 3 episodes More than 2 episodes with early age of onset or reoccurrence within 2 years of stopping anti depressants chronic depression

Electrconvulsive Therapy(ECT) Indications for ECT : Severe depression with suicidal risk Severe depression with stupor Catatonia Treatment refractory depression Delusional depression Intolerance to drugs

Psychosocial treatment Cognitive behavior therapy Behavior therapy Group therapy Family and marital therapy

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