1. AFFECTIVE DISORDERS DR. Rabie A. Hawari Consultant Psychiatrist Clinical Assistant Professor

2. AFFECTIVE DISORDERS A group of illness of variable severity in which the central symptom is periodic alteration of mood into either Mania or Depression.

3. Epidemiology female: male = 2:1 (dep.) = 1:1 ( mania) age = dep. – 20-50. mean 40yr. = mania – earlier mean 30yr

4. Etiology various theories Genetics :- evidence is stronger for BAD, - 50% of pts.---> one parent have M.D, - BAD. pt. ----> 27% any child have M.D, - Both parents ----> 50-75% any child, - MZ twins ----> 75% concordance. Biochemical :- - Norepinephrine & Serotonin reduced at receptor sites in the brain ---- > dep. - NE & 5HT increased at receptor sites ---> mania.. Psychological Factors :- - Life Events. – P.M.P. – Psychoanalytic. - Cognitive. – learned helplessness.

5. DEPRESSION

6. Signs & Symptoms A. Mental:- Mood:- Depressed, Diurnal Variation, Pessimism, Suicidal ideas, Loss of Interest, Anhedonia. Thinking:- Poverty of thoughts, poor concentration, Poor cognition, poor judgment & insight, Delusions (paranoid, guilt, nihilistic, hypochondriases) Perception: - Auditory Hallucination,(2nd. Person).

7. Signs & Symptoms( cont ) B. Physical :-. Insomnia or Hypersomnia, Loss of Appetite, Loss of Wt. or Gain, Psychomotor Retardation or Agitation, Loss of Libido, Loss Energy, Tiredness, stupor. Somatic c/o:- headache, constipation,drymouth,abnormal menses, etc.

8. Types of depression 1. Major Depression: - unipolar – s/s. 2/52, 40ys. 2. Dysthymia: - Neurotic depression. Chronic. 20 s. 3. Seasonal Affective disorder (SAD): - - Major dep., in winter & fall (short daylight) - s/s: hypersomnia, hyperphagia & psychomotor slowing - due to abn.Melatonin metabolism, - Rx. Exposure to light 3-6 hr. /day. 4. Post Partum Depression: - after birth. 30 days. s/s.insomnia, fatigue, suicide, homicide & delusions.

9. Types of depression( cont.) 5. Myxedema Madness : - HypothyroidismS/s.fatigability, Dep. suicidal impulse, delusions, hallucination & Paranoia. 6. Organic Mood Disorder- - Depression type: - secondary to organic cause e.g. Cushing’s Synd., Propranlol med., Infections (flu, Aids,). 7. Pseudo Dementia : - Dementia Synd. Of depression in the elderly. Dep. Is primary than the cognitive dysfunction 8. Adjustment Diso. with Depressed Mood : - response to a clear identifiable stress.

10. Types of depression( cont.) 9. Grief: - sadness secondary to major loss.—not Dep., remits with time, no suicide or helplessness. 10. Depression in children: - not uncommon, same s/s. Masked dep. = running away from home, school Phobia, substance abuse & suicide. 11. Double Dep.: - Major dep. On top of dysthymia. 12. Atypical Dep.: - s/s. do not meet criteria of depression - intermittent dysthymic episodes, - Wt. gain & hypersomnia.

12. Treatment of Depression Pharmacological:- a. TCA: - Imipramine, Amitriptyline,Clomipramine, (3/52 to start to act). b. MAOI: - Phenelzine, Parnate (Tyramine dietary restrictions). c. SSRIs: - Fluvoxamine, fluoxetine, “Rx. For 6/12. if recurrent lithium as an adjunct appears to be affective “ * Physical :- ElecrtoConvulsiveTherapy (ECT).

13. Treatment of Depression (cont) Psychological:- a). Cognitive: corrections of chronic distortions in thinking which led to depression. b). Behaviour: aimed at specific behaviour. c). Interpersonal: emphasis on ongoing current issues. d). Psychoanalytic: to understand the unconscious conflicts & motivations that might sustain depression. e). Group Rx. f). Family Rx. g). Supportive Rx.

14. MANIA

15. Signs & Symptoms A. Menta l:- - Mood:- Elevated (Elated) mood over days or weeks. - may be interrupted by episode of depression, - Irritability with Angry outbursts. - Impulsiveness. -Thinking:- - Low concentration, Distractibility, - Over talkative, Laud, Rapid, - Pressure of thoughts, - Flight of Ideas, - Memory & Orientation = intact, - Judgment & Insight = impaired, - Delusions = Grandiose, Paranoid, - Inflated self-esteem. - Perception: - Hallucination may be present.

16. Signs & Symptoms ( cont ) B. Physical : - Insomnia, - Increase activities & energy, - Increase Libido, Disinhibtion, - Psychomotor agitation, - Wt. loss due exhaustion.

18. TYPES OF MANIA Organic Mood Disorder: - Manic Type. Secondary to organic disorder e.g. – Tertiary Syphilis, Influenza, Corticosteroids, TLE, Amphetamine, Hyperthyroidism, Head Trauma, Vit. Def. (B12, Folate, Thiamine), MS Cyclothymia: - 2yrs. Symptoms, recurrent mood swings Rapid Cycling Bipolar Disorder: - Mania/Depression Episodes with intervals 48-72 hrs. Bipolar Disorder not otherwise specified (NOS):- 1 Depression episode & 1 manic episode.

19. Treatment of Bipolar Disorder :- A. Pharmacological:- : Lithium = effective in 80%,-- takes 7-10 days,-- full trail at least for 4 wks.,-- blood level 0.6 – 1.2 mEq/L,-- starting dose 300mg tid,- usual dose range 900-2000mg per day,-- toxicity more than 1.2mEq/L. : Carbamazepine = dose 200mg bid / day,-- increase by 200mg. every wk. until plasma level 6 -12 mg/L. : Valporic acid = ½ life 8 hrs.,-- peak 1- 4 hrs.,-- starting dose 500 mg, -- range 750 – 3000 mg,-- therapeutic level 40 – 100 ug/mL, -- toxic 200 ug/Ml. : Clonazepam = dose in acute mania 2 – 16 mg/day.

20. Treatment of Bipolar Disorders( con ) : Typical Antipsychotic = -Haloperidol – oral, I.M., I.V., dose 5 – 60 mg. - Clopixol – oral10-60 mg., I.M.Aquaphase 50-100mg - Chlorpromazine – oral, dose 100 – 2000 mg/day. : Atypical Antipsychotic = - Risperidone – oral, dose 2 – 8 mg./day Risperidal Consta-i.m.(25-37.5-50mg)X2/52 - Zyprexa – oral, I.M., dose 5 – 20 mg./day. B. Psychological: - when Pt. is controlled with medications.

21. COURSE & PROGNOSIS Depression: - - 15% commit suicide. - Untreated – episode last for 10 months. - 75% have secondary episode after 6/12 - Average No. of episodes in lifetime = 5. PROGNOSIS: - –50% recover. – 30% partially recover. –20% have chronic course. –20-30% of Dysthymic or cyclothymic develop major Dep., or mania.

22. COURSE & PROGNOSIS (cont) Mania; - - 45 % recur. - Untreated – episode last 3-6 months. High rate of recurrence average 10. -80-90 % experience a full Dep., episode. PROGNOSIS : - –fair. –15 % recover. – 50 – 60 % partially recover –1/3 have some evidence of chronic symptoms & social deterioration.