Psychiatry lec.6.pdf

‫)‪Mood Disorders (Affective disorders‬‬ ‫الدكتور‬ ‫علي لطيف السلطاني‬ ‫شهادة البورد )الدكتوراه(في الطب النفسي‬ ‫)‪F.I.C.M.S(Psych.‬‬  Mood Disorders (Affective disorders) ❑Mood can be defined as a pervasive and sustained emotion or feeling ton...

‫)‪Mood Disorders (Affective disorders‬‬ ‫الدكتور‬ ‫علي لطيف السلطاني‬ ‫شهادة البورد )الدكتوراه(في الطب النفسي‬ ‫)‪F.I.C.M.S(Psych.‬‬  Mood Disorders (Affective disorders) ❑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. ❑Mood Disorders —sometimes called affective disorders —make up an important category of psychiatric illness consisting of depressive disorder, bipolar disorder, and other disorders.. ❑Mood: is the sustained internal emotional state of the person, while the affect is defined as the objective and behavioral expression of internal mood states with concomitant observable motor components, in the form of expressive features of facial and other body movements. ❑Mood may be normal (euthymic), elevated or depressed. · Brieffluctuations of mood between sadness and happiness in response to events and circumstances is normal and require no treatment. · Lack of emotions is abnormal · In mood disorders, the sense of control is lost, and people experience great distress. · Persistent mood changes downward (depression) and upward (mania) are abnormal, and with additional symptoms, constitute disorders or syndromes.  Classification of mood disorders Bipolar and Related Disorders Depressive Disorders Bipolar I Disorder Disruptive Mood Dysregulation Disorder Bipolar II Disorder Major Depressive Disorder, Single Episode Cyclothymic Disorder Major Depressive Disorder, Recurrent Episode Substance/Medication-Induced Bipolar and Persistent Depressive Disorder (Dysthymia) Related Disorder Premenstrual Dysphoric Disorder Bipolar and Related Disorder Due to Another Substance/Medication-Induced Depressive Medical Condition Disorder Other Specified Bipolar and Related Disorder Depressive Disorder Due to Another Medical Condition Unspecified Bipolar and Related Disorder Other Specified Depressive Disorder Unspecified Depressive Disorder Fig. 6.1: Bipolar Disorder: Clinical Picture  Major Depressive Disorder )MDD( ❑Major depressive disorder (unipolar depression) is reported to be the most common mood disorder. ❑It is characterized by one or more major depressive episodes (at least 2 weeks of depressed mood or loss of interest )accompanied by at least four additional symptoms of depression. ❑The peak ages of incidence of MDD are 18–44 years. ❑It may occur in childhood or in the elderly. The prevalence of MDD is ~1% in preschool-age children, 2% in school-age children, and 8% in adolescents. Lifetime prevalence is in the range of 15 - 25 %. the two-fold greater prevalence of the disorder in women than in men. The reasons for this difference have been hypothesized to involve hormonal differences, the effect of childbirth, and differing psychosocial stresses for women and for men. Persistent Depressive Disorder (Dysthymia) : is a chronic low-grade depression characterized and defined by the presence of a depressed mood for at least 2 years (or 1 year in children and adolescents) and at least two of six designated symptoms of depression that are present most (>50%) of the time and that result in clinically significant distress or impairment.  Etiology Although the etiology of MDD is ambiguous and complex, it can be divided into three main groups: biological, genetic, and psychosocial. 1-Biological factors: a. Biogenic amines low brain levels of 5-HT, norepinephrine (NE), and/or dopamine (DA) in the limbic system (“mood center”) are associated with depression c. Neuro-endocrine regulation: Depression is linked to the hypothalamic-pituitary-adrenal (HPA) axis and cortisol production. d. brain imaging abnormalities: still inconclusive. 2-Genetic factors: Genetic data strongly indicate that significant genetic factor is involved in the development of mood disorders. First degree relatives of MDD are 1.5-2.5 times more likely to have bipolar I disorder, and 2-3 times to have MDD. The concordance rate for MZ twins is about 50% while in DZ twins is 10-25%. 3. Psychosocial factors: a- life events and environmental stress: MDD develops as a consequence of stressful life events or losses. Four of the most powerful stressors are: Death of a close relative. Being a victim of assault. Having serious marital problems. Dealing with separation or divorce.  b- Family: Depression results from early childhood losses that lead to insecurity, difficulty in establishing attachments in adult life, dependency on others, low self- esteem, and vulnerability to losses. c- premorbid personality factors. d- Learned helplessness model: Past failures will continue unabated. e- Cognitive (Beck) model: Negative views lead to depression and can be corrected through cognitive therapy.  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. A depressed mood and a loss of interest or pleasure are the key symptoms of depression. 1. Depressed mood: Depressed mood is sustained emotional states, most of the day(> 50%) , nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others The patient often describes it as a profound sense of hopelessness or internal emptiness. 2. Anhedonia: markedly diminished 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).  Several vegetative signs and symptoms are included in the criteria for a 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 in appetite nearly every day. 4. The patterns of insomnia include initial insomnia (difficulty falling asleep), middle insomnia (awaking during the night), and terminal insomnia(early awaking and difficulty falling back asleep) 5. Altered psychomotor activity is expressed in agitation or retardation. Psychomotor agitation is an inner irritability with an objective motor component. 6. Fatigue and loss of energy may be subjective, objective, or both.  Cognitive Functions & Thinking: 7-Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 8-Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 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.  B- The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C- The episode is not attributable to the physiological effects of a substance or to an-other medical condition. E. There has never been a manic episode or a hypomanic episode. Psychotic Features Associated with Severe Depression A. Delusions (mood-congruent) Delusion of guilt (patient believes he deserves severe punishment). Nihilistic delusion (patient believes that some part of his body ceased to exist or function, e.g. bowel, brain…). Delusion of poverty and impoverishment. Persecutory delusion B. Hallucinations (mood-congruent) Usually second person auditory hallucinations. Visual hallucinations (scenes of death and destruction) may be experienced by a few patients Appearance & Behaviour: Neglected dress and grooming. Facial appearance of sadness: turning downwards of corners of mouth. down cast gaze. tearful eyes. reduced rate of blinking. head is inclined forwards.  Course of Illness: Recurrent Versus Single Episode For a major depressive disorder to be considered recurrent, there must be an interval of at least 2 consecutive months between separate episodes in which criteria are not met for a major depressive episode. The first depressive episode occurs before age 40 years in about 50 percent of patients. Later onset is associated with the absence of a family history of mood disorders, antisocial personality disorder, and alcohol abuse.  An untreated depressive episode lasts 6 to 13 months; most treated episodes last about 3 months. The withdrawal of antidepressants before 3 months has relapsed almost always results in the return of the symptoms. Approximately 20% of episodes becoming chronic (i.e., lasting beyond 2 years). As the course of the disorder progresses, patients tend to have more frequent episodes that last longer. Over 20 years, the mean number of episodes is five or six.  Prognosis Major depressive disorder is not a benign disorder. It tends to be chronic and patients tend to relapse. Recurrences are also common. The incidence of relapse is lower in patients who continue prophylactic psychopharmacological treatment. Generally, as patient experiences more and more depressive episodes, the time between episodes decreases and the severity of each episode increases.  Suicide Risk Features associated with an increased risk for completed suicide include: male sex. being single or living alone. prominent feelings of hopelessness. The presence of borderline personality disorder markedly increases risks for future suicide attempts.  Differential Diagnosis Mood disorder caused by a general medical condition: 1.CNS disorders:(right sided cerebral vascular lesions and lesions in the frontal and temporal lobes) Neurological disorders as stroke ,head ,trauma ,brain tumor , dementia ,epilepsy , and multiple sclerosis. 2. Endocrine causes: thyrotoxicosis , Cushing syndrome. 3. Depression secondary to medications. 4. Psychiatric disorders: Dysthymic disorder (less severe, and chronic). Adjustment disorder with depressed mood. Substance - induced mood disorder. Schizophrenia, schizoaffective disorder. Somatization disorder  Treatment ❑Aims of treatment include ▪The patient’s safety should be guaranteed. ▪Complete diagnostic evaluation. ▪Treatment plan that addresses not only the immediate symptoms but also the patient’s prospective wellbeing. ▪Treatment must reduce the number and severity of stressors in the patient’s life. Hospitalization The first and most critical decision is whether to hospitalize the patient or to attempt outpatient treatment. ❑Indications for hospitalization include: ▪ Need for diagnostic procedures. ▪ Risk of suicide or homicide. ▪ Patient’s grossly reduced ability to get food and shelter. ▪ History of rapidly progressing symptoms. ▪ Rupture of the patient’s usual support systems.  Psychosocial Therapies ❑These include three types: ▪ Psychoeducation (patient and family –illness,medic,symptoms) ▪ CBT. ▪ Interpersonal therapy. ▪ Social therapy. ▪ Supportive therapy ▪ family therapy.  Pharmacotherapy ❑Tricyclic antidepressants: Examples: amitriptyline, imipramine, clomipramine, maprotiline, trimepramie, desipramine, etc… ▪ Advantages: well-established efficacy and large literature (in all varieties of patient groups); possibly more effective in severe depression; low cost. ▪ Disadvantages: toxicity in overdose; may be less well tolerated than SSRIs; all TCAs may slow cardiac conduction and lower seizure threshold. ▪ Contraindications: acute MI, heart block, arrhythmias, IHD, severe liver disease, pregnancy and lactation. ▪ Cautions : cardiovascular, liver, renal disease; endocrine disorders (hyperthyroidism, adrenal tumours, diabetes); urinary retention/prostatic hypertrophy; constipation; glaucoma; epilepsy; psychotic disorders; patients with thoughts of suicide; elderly (use lower doses). ❑Serotonin-specific reuptake inhibitors (SSRIs): ▪fluoxetine, paroxetine, citalopram, escitalopram, sertraline and fluvoxamine. ▪Advantages: may be better tolerated than TCAs—less cardiotoxic; fewer anticholinergic side-effects; low toxicity in overdose. ▪Disadvantages: commonly cause nausea and GI upset, headache, restlessness, and insomnia; may be less effective for severe depressive episodes; problems on discontinuation. ▪Contraindications: manic episode, concomitant use of MAOIs. ❑Monoamine oxidase inhibitors (MAOIs): ▪ Side-effects: Risk of hypertensive crisis due to inhibition of intestinal MAO, allowing pressor amines to enter the bloodstream (hence foods high in tyramine and certain medications should be avoided). ▪ Sources of dietary tyramine: cheese, meat extracts and yeast extracts, alcohol —including low-alcohol drinks, non-fresh fish, non-fresh poultry, offal, avocado, banana skins, broad-bean pods, caviar, herring. ▪ Medications: indirect sympathomimetics (amfetamine, fenfluramine, ephedrine, phenylephrine, phenylpropanolamine), cough mixtures containing sympathomimetics, nasal decongestants with sympathomimetics, levodopa (L- dopa),pethidine, antidepressants (TCAs, SSRIs/SNRIs, mirtazapine , bupropion, St John’s wort. ▪ However, large amounts of tyramine-rich food should be avoided.  Other side-effects: antimuscarinic actions, hepatotoxicity, insomnia, anxiety, appetite suppression, weight gain, postural hypotension, ankleoedema, sexualdysfunction, possible dependency. Indications: usually used as second-line therapy for treatment-resistant depression (particularly atypical symptoms)/anxiety disorders (with or without panic attacks). Cautions: cardiovascular disease, hepatic failure, poorly controlled hypertension, hyperthyroidism, porphyria, phaeochromocytoma. Advantages: well-established efficacy in a broad range of affective and anxiety disorders. ❑Serotonin/noradrenaline reuptake inhibitors (SNRIs) Venlafaxine (Efexor), Duloxetine (Cymbalta) Mode of action: 5-HT and NE reuptake inhibition. Common adverse effects: nausea, GI upset constipation, loss of appetite, dry mouth, dizziness, agitation, insomnia, sexual dysfunction, headache, nervousness, sweating, weakness. Electro-convulsive therapy (ECT): Indications Depressive episode: ▪ severe episodes, ▪ need for rapid antidepressant response (e.g. due to failure to eat or drink in depressive stupor; high suicide risk) ▪ failure of drug treatments ▪ patients who are unable to tolerate side-effects of drug treatment (e.g. puerperal depressive disorder ▪ previous history of good response to ECT ▪ patient preference. ▪ Other indications: ▪ treatment-resistant psychosis and mania (50–60% effective), ▪ schizoaffective disorder ▪ Catatonia ▪ neuroleptic malignant syndrome ▪ neurological crises (e.g. extreme Parkinsonian symptoms: on–off phenomena), ▪ intractable seizure disorders (acts to raise seizure threshold).