Mood Disorders PDF

NATIA BADRIDZE,MD  Mood Disorders I. Clinical Descriptions and Epidemiology of Mood Disorders II. Etiology of Mood Disorders III. Treatment of Mood Disorders  Two broad types: Involves only depressive symptoms Involves manic symptoms (bipolar disorders) ...

NATIA BADRIDZE,MD  Mood Disorders I. Clinical Descriptions and Epidemiology of Mood Disorders II. Etiology of Mood Disorders III. Treatment of Mood Disorders  Two broad types: Involves only depressive symptoms Involves manic symptoms (bipolar disorders)  DSM-IV-TR depressive disorders: Major depressive disorder Dysthymia (renamed persistent depressive disorder in DSM-V)  DSM-5 adds two new depressive disorders: Premenstrual dysphoric disorder Disruptive mood dysregulation disorder  DSM-IV-TR/DSM-5 Bipolar Disorders: Bipolar I disorder Bipolar II disorder Cyclothymia  Mood can be defined as a pervasive and sustained emotion or feeling tone that influences a person’s behavior and colors his or her perception of being in the world.  Disorders of mood—sometimes called affective disorders—make up an important category of psychiatric illness consisting of depressive disorder, bipolar disorder, and other disorders.  Mood can be labile,fluctuating or alternating rapidly between extremes (e.g., laughing loudly and expansively one moment, tearful and despairing the next).  Other signs and symptoms of mood disorders include changes in activity level, cognitive abilities, speech, and vegetative functions (e.g., sleep, appetite, sexual activity, and other biological rhythms).  These disorders virtually always result in impaired interpersonal, social, and occupational functioning.  Patients with only major depressive episodes are said to have major depressive disorder or unipolar depression.  Patients with both manic and depressive episodes or patients with manic episodes alone are said to have bipolar disorder.  The terms “unipolar mania” and “pure mania” are sometimes used for patients who are bipolar but who do not have depressive episodes.  Sad mood OR loss of interest or pleasure (anhedonia) Symptoms are present nearly every day, most of the day, for at least 2 weeks Not due to normal bereavement (present in DSM-IV-TR but removed in DSM-5)  PLUS four of the following symptoms: Sleeping too much or too little Psychomotor retardation or agitation Poor appetite and weight loss, or increased appetite and weight gain Loss of energy Feelings of worthlessness or excessive guilt Difficulty concentrating, thinking, or making decisions Recurrent thoughts of death or suicide  Recurrent Once depression occurs, future episodes likely  Average number of episodes is 4  Subclinical depression Sadness plus 3 other symptoms for 10 days Significant impairments in functioning even though full diagnostic criteria are not met  Depressed mood for at least 2 years; 1 year for children/adolescents PLUS 2 other symptoms:  Poor appetite or overeating  Sleeping too much or too little  Poor self-esteem  Trouble concentrating or making decisions  Feelings of hopelessness  Chronicity of symptoms stronger predictor of negative outcomes than number of symptoms  In most menstrual cycles during the past year, at least five of the following symptoms were present in the final week before menses and improved within a few days of menses onset: Affective lability Irritability Depressed mood, hopelessness Anxiety Diminished interest in usual activities Difficulty concentrating Lack of energy Changes in appetite, overeating, or food craving Sleeping too much or too little Subjective sense of being overwhelmed or out of control Physical symptoms such as breast tenderness or swelling, joint or muscle pain, or bloating  Severe recurrent temper outbursts, including verbal or behavioral expressions of anger/temper that are out of proportion in intensity or duration to the provocation.  The temper outbursts tend to occur at least three times per week.  Negative mood between temper outbursts most days.  These symptoms have been present for at least 12 months.  Temper outbursts and negative mood are present in at least two settings (at home, at school, or with peers) and are severe in at least one setting.  Onset before age 10.  Depression is common Lifetime prevalence  16.2% MDD  2.5% Dysthymia Twice as common in women as in men Three times as common among people in poverty  2/3 of those with MDD will also meet criteria for anxiety disorder at some point  Median age of onset is now in late teens and early 20s.  With each generation, the median age of onset for MDD gets younger  Three forms: Bipolar I, Bipolar II, and Cyclothymia  Mania defining feature of each  Differentiated by severity and duration of mania Usually involve episodes of depression alternating with mania Mania State of intense elation or irritability Hypomania (hypo = “under”; hyper = “above”)  Symptoms of mania but less intense  Does not involve significant impairment, mania does  Distinctly elevated or irritable mood for most of the day nearly every day  Abnormally increased activity and energy  At least three of the following are noticeably changed from baseline (four if mood is irritable): Increase in goal-directed activity or psychomotor agitation Unusual talkativeness; rapid speech Flight of ideas or subjective impression that thoughts are racing Decreased need for sleep Increased self-esteem; belief that one has special talents, powers, or abilities Distractibility; attention easily diverted Excessive involvement in activities that are likely to have undesirable consequences, such as reckless spending, sexual behavior, or driving  For a manic episode: Symptoms last for 1 week or require hospitalization Symptoms cause significant distress or functional impairment Psychotic symptoms present  For a hypomanic episode: Symptoms last at least 4 days Clear changes in functioning that are observable to others, but impairment is not marked No psychotic symptoms are present  Bipolar I At least one episode of mania  Bipolar II At least one major depressive episode with at least one episode of hypomania  Cyclothymic disorder (Cyclothymia) Milder, chronic form of bipolar disorder  Lasts at least 2 years in adults, 1 year in children/adolescents Numerous periods with hypomanic and depressive symptoms  Does not meet criteria for mania or major depressive episode  Symptoms do not clear for more than 2 months at a time  Prevalence rates lower than MDD 0.6% worldwide for Bipolar I 0.4% – 2% for Bipolar II 4% for Cyclothymia  Average age of onset in 20s  No gender differences Women experience more depressive episodes  Severe mental illness Suicide rates are high  What factors contribute to onset of mood disorders? Neurobiological factors Psychosocial factors  Genetic factors Heritability estimates  37% MDD (Sullivan et al., 2000)  93% Bipolar Disorder (Kieseppa et al., 2004) Much research in progress to identify specific genes involved but the results of most studies have not been replicated DRD4.2 gene, which influences dopamine function, appears to be related to MDD.  Neurotransmitters (NTs): norepinephrine, dopamine, and serotonin Original models focused on absolute levels of NTs  MDD  Low levels of norepinephrine, dopamine, and serotonin  Mania  High levels of norepinephrine and dopamine, low levels of serotonin However, medication alters levels immediately, yet relief takes 2-3 weeks  New models focus on sensitivity of postsynaptic receptors Dopamine receptors may be lack sensitive in MDD Depleting tryptophan, a precursor of serotonin, causes depressive symptoms in individuals with personal or family history of depression  Individuals who are vulnerable to depression may have less sensitive serotonin receptors  Overactivity of HPA axis Triggers release of cortisol, stress hormone  Amygdala overreactive  Findings that link depression to high cortisol levels Cushing’s syndrome  Causes oversecretion of cortisol  Symptoms include those of depression Injecting cortisol in animals produces depressive symptoms  Life events Prospective research  42-67% report a stressful life event in year prior to depression onset  e.g., romantic breakup, loss of job, death of loved one Lack of social support may be one reason a stressor triggers depression  Interpersonal Difficulties High levels of expressed emotion ( critical or emotional involvement) by family member predicts relapse Marital conflict also predicts depression  Cognitive theories Beck’s Theory  Negative triad: negative view of self, world, future  Negative schema: underlying tendency to see the world negatively  Negative schema cause cognitive biases: tendency to process information in negative ways Hopelessness Theory  Most important trigger of depression is hopelessness  Desirable outcomes will not occur  Person has no ability to change situation © 2012 John Wiley & Sons, Inc. All rights reserved.  Triggers of depressive episodes in bipolar disorder appear similar to the triggers of major depressive episodes Negative life events, neuroticism, negative cognitions, expressed emotion, and lack of social support  Predictors of Mania Reward sensitivity (highly responsive; even positive events, like marriage) Sleep disruption  Interpersonal psychotherapy (IPT) Short-term psychodynamic therapy Focus on current relationships  Cognitive-behavioral therapy Monitor and identify automatic thoughts  Replace negative thoughts with more neutral or positive thoughts  Mindfulness-based cognitive therapy (MBCT) Strategies, including meditation, to prevent relapse  Psychoeducational approaches  Provide information about symptoms, course, triggers, and treatments  Electroconvulsive therapy (ECT) Reserved for treatment non-responders Induce brain seizure and momentary unconsciousness  Unilateral ECT Side effects  Memory loss ECT more effective than medications  Unclear how ECT works  Lithium Up to 80% receive at least some relief with this mood stabilizer Potentially serious side effect  Lithium toxicity  Newer mood stabilizers Anticonvulsants  Depakote Antipsychotics  Zyprexa Both also have serious side effects THANK YOU