Transcript and major depressive disorder

Affect disorders. Mask depression. Epilepsy.
Etiology and pathogeny. Classification.
Epileptic psychoses. Patients with changes of
personality on epileptic type.
Sadness
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All of us have experienced sadness, the undesired
emotion which accompaniesundesired events, such as
loss of a valued object or individual, or failure to
achieve adesired goal. While healthy people report
days when they are “a bit down” for no
apparent reason, in healthy people, significant sadness
occurs only as a reaction to events.
In the mood disorders, the mood shifts excessively in
response to minor events, or autonomously, that is, in
the absence of stimulating events, and once shifted
the pathological mood position is sustained
Grief
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Grief is the term applied to the unpleasant
experience of having lost a significant other person.
While this experience can result from the loss of
inanimate objects, such as a valuable art works
collected over a lifetime, grief most commonly occurs
with the loss of an individual who has been
important in our lives. Grief is emotional pain,
accompanied by a longing for the return of the lost
object, and a feeling of loss, emptiness and
incompletenes s. In Western cultures there may be
crying, insomnia and loss of appetite. There may be
a sense of guilt at being alive in the absence of the
important other, and auditory and visual
hallucinations of the lost individual.
Culture influences the expression and
experience of grief.
Some cultures prescribe the behaviour and dress of the
bereaved, and even the precise length of the grieving/mourning
process. The details vary depending on the nature of the
relationship (universally, spouses grieve longer than siblings).
There are advantages of an established grieving protocol. The
bereaved individual, who is distressed and finds making
decisions difficult, has a clear scrip turitual to follow. Adhering to
the ritual ensures no one is offended during this emotional time.
Also, once all steps/obligations have been fulfilled there is a
sanctioned end to the grieving, and the bereaved are to return
to their usual life .
Grief
The grief reaction is considered to have become
“pathological” when it persists longer than usual or
has unusual features (Nakamura, 1999). There is
concern when the grief is not abating some months
after the death. It is generally believed the grieving
process takes 6 to 12 months.
 Unusual features which identify pathological grief
include distress to a much greater degree than is
culturally sanctioned. The bereaved individual who
has not eaten or slept and is inconsolable one week
after the event is suffering excessively
SADNESS AND DEPRESSION
SADNESS AND DEPRESSION
When pathological guilt is suspected, it is im
portant to exclude other diagnosable conditions
(major depressive disorder or anxiety disorders)
which may have been triggered by the loss.
Along with grief counselling and support, any co
-morbid disorders should be treated in the
standard manner.
Grief and pathological grief are yet to be fully
elucidated. For example, what does “recovery”
mean following the loss of a spouse of 50 years?
Pathological grief is not listed in the DSM-IV.
Depression
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We all suffer sadness in response to undesired events such as
loss. In this section, those psychiatric disorders will be outlined,
in which the mood is changed in the direction of
sadness/depression . It is important to be aware that in these
disorders, mood change is not the only symptom; others include
vegetative symptoms such as sleep and appetite change. Thus,
these disorders are diagnosed using batches or patterns of

symptoms.
The main disorders include major depressive disorder, bipolar
depression and dysthymia. Until recent times it was considered
that the depressed episode in major depressive disorder and
bipolar depression were much the same.
Depression
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This is now in doubt; certainly bipolar depression presents a
greater challenge to the clinician. Dysthymia is distressing
condition, but the depth or the sadness and impairment of
function is less severe than major depressive disorder and
bipolar depression.
Major depressive episode
A major depressive episode is a batch or
pattern of symptoms, which is the same for
depressive disorder and bipolar
depression. The final diagnosis of major
depressive disorder as opposed to bipolar
depression depends on whether there has
been an episode of mania (pathological
mood elevation) in the past.
Criteria for major depressive episode:
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1. At least one of the following for at least two weeks:
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persistent depressed mood
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loss of interest and pleasure.
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2. At least four of the following:
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significant weight loss or gain, insomnia or
increased sleep, agitation (worrying and physical
restlessness) or retardation (slowed thinking and
moving), fatigue or loss of energy
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feelings of worthlessness or inappropriate guilt
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diminished ability to concentrate or indecisiveness
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thoughts of death or suicide.
Major depressive episode
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Major depressive disorder is diagnosed when there
is/has been one or more major depressive episodes
and no history of mania or hypomania
This serious disorder causes great suffering and
may end in suicide. The prevalence in Western
societies is 5.4 to 8.9 % (Narrow et al, 2002). A
recent modelling study found that close to half the
population can expect one or more episodes of
depression in their lifetime (Andrews et al, 2005).
The prevalence of depressive disorder is twice as
common in females. The average age of onset is in
the mid -20s.
Major depressive episode
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80% of people who suffer a major depressive episode will have
recurrent episodes. The clinical course of depression is not as
favourable as was once believed. In fact, at one year follow up,
only 40% of patients are symptom free, 20% have some
residual symptoms, and the final 40% still have depressive
disorder.
About 15% of people with either depressive disorder or bipolar
disorder die by suicide.
Abnormalities in a range of neurotransmitter have been
proposed, including serotonin, norepinephrine, dopamine,
GABA, brain derived neurotrophic factor, somatostatin,
acetylcholine, corticotropin releasing factor, and substance P.
Major depressive episode
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Aetiology
Heritability of depression is estimated to be in the range 3142% . No single gene for major effect have been identified. A
multitude of genes with small effect are likely to be involved,
which interact with environmental factors.
In addition to genetic factors, other risk factors include neurotic
personality traits, low self-esteem, early onset anxiety, a history
of conduct disorder, substance use, adversity, interpersonal
difficulties, low parental warmth, childhood sexual abuse, low
eduction, lifetime trauma, low social support , divorce and
stressful life events
Bipolar depression
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In the mid 1960’s the conclusion was
drawn that bipolar disorder (formerly
manic depressive psychosis) and major
depressive disorder (also termed
unipolar depression) are different
disorders
Bipolar depression
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The depressive episodes seen in bipolar
disorder, in contrast to those typically seen in a
major depression, tend to come on fairly
acutely, over perhaps a few weeks, and often
occur without any significant precipitating
factors. They tend to be characterized by
psychomotor retardation, hyperphagia, and
hypersomnolence and are not uncommonly
accompanied by delusions or hallucinations. On
the
average,
untreated,
these
bipolar
depressions tend to last about a half year.
– Mood is depressed and often irritable. The
patients are discontented and fault-finding
and may even come to loathe not only
themselves but also everyone around them.
Bipolar depression
Patients may lose interest in life; things appear dull and heavy and have
no attraction. Many patients feel a greatly increased need for sleep.
Some may succumb and sleep 10, 14, or 18 hours a day. Yet no matter
how much sleep they get, they awake exhausted, as if they had not slept
at all. Appetite may also be increased and weight gain may occur,
occasionally to an amazing degree. Conversely, some patients may
experience insomnia or loss of appetite.Psychomotor retardation is the
rule, although some patients may show agitation. In psychomotor
retardation the patient may lie in bed or sit in the chair for hours,
perhaps all day, profoundly apathetic and scarcely moving at all. Speech
is rare; if a sentence is begun, it may die in the speaking of it, as if the
patient had not the energy to bring it to conclusion. At times the facial
expression may become tense and pained, as if the patient were under
some great inner constraint.
Bipolar depression
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Pessimism and bleak despair permeate these patients' outlooks.
Guilt abounds, and on surveying their lives patients find
themselves the worst of failures, the greatest of sinners. Effort
appears futile, and enterprises begun in the past may be
abandoned. They may have recurrent thoughts of suicide, and
impulsive suicide attempts may occur.
Delusions of guilt and of well-deserved punishment and
persecution are common. Patients may believe that they have
let children starve, murdered their spouses, poisoned the wells.
Unspeakable punishments are carried out: their eyes are
gouged out; they are slowly hung from the gallows; they have
contracted syphilis or AIDS, and these are a just punishment for
their sins.
Bipolar depression
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Hallucinations may also appear and may be quite
fantastic. Heads float through the air; the soup boils
black with blood. Auditory hallucinations are more
common, and patients may hear the heavenly court
pronounce judgment. Foul odors may be smelled, and
poison may be tasted in the food.
In general a depressive episode in bipolar disorder
subsides gradually. Occasionally, however, it may
come to an abrupt termination. A patient may arise
one morning, after months of suffering, and
announce a complete return to fitness and vitality. In
such cases, a manic episode is likely to soon follow.
Dysthymia
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In dysthymia, patients present with extremely
chronic yet low-level depressive symptoms that seem
to pervade their entire existence— past, present, and
probably future.
Dysthymia is in 3 times more frequent among
females than males, and appears to be a common
condition, with a lifetime prevalence of about 6%.
The fact that the vast majority of patients with
dysthymia also at some point experience a full
depressive episode argues for an identity between
the two disorders; however, a small percentage of
patients with dysthymia never experience a full
depressive episode throughout their lives.
Dysthymia
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Mood is typically depressed and sorrowful; at times some querulousness or
irritability may occur. The outlook is pessimistic, even somber. Everything is
taken too seriously, and life is seen as an opportunity only for toil. Though
joyous occasions, such as a promotion, graduation, or the birth of a child,
may temporarily lift these patients to some warmth and appreciation, they
typically sink again quickly back into misery.
Self-confidence is lacking. New tasks or stresses seem hopelessly difficult,
and although patients may shoulder their burdens with grim determination,
in their hearts they expect only failure. Thinking is difficult. Patients may
complain of feeling heavy-headed and slow and of not being able to
concentrate. Irresolution is common, and decisions may be postponed,
again and again. Fatigue is common, and patients may complain of feeling
exhausted much of the time. Hypochondriacal concerns may appear.
Patients may worry over minor headaches or gastrointestinal upset, and
this may occasion numerous trips to the physician. Appetite may suffer, and
some patients may lose weight. Difficulty falling asleep is common, and
some patients complain of restless, broken sleep.
MOOD ELEVATION DISORDERS
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Pathological mood elevation is conceptualized as two levels:
mania (the highe r level), and hypomania (under or less than
mania). Hypomanic symptoms may occur in both bipolar
disorder and the eleva ted phase of cyclothymia. As these are
matters of degree and judgement, in a particular case, clinicians
may disagree on the most appropriate designation. This is of
little importance. The important issue it to identify when
treatment is indicated, and to pro vide that treatment.
Mood elevation often presents with euphoria,
disinhibition and friendliness
MOOD ELEVATION DISORDERS
A middle aged woman was admitted with mania. While on the ward she
used acrylic paint to adorn her jeans with word includin g Joy, Love,
Peace, Kindness
and Patients. Across the seat she painted “I love (indicated by a symbol of
a heart)
life”. These additions reflected her euphoria, but also her lack of inhibition and
poor
judgement. When she recovered she regretted ruining ne w and expensive
clothing
(which she had purchased during a manic buying spree).
MOOD ELEVATION DISORDERS
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The DSM-IV diagnostic criteria for a manic episode:
– A. A distinct period of abnormally and persistently elevate d,
expansive, or
 irritable mood, lasting at least one week (or any duration if
hospitalization is necessary).
– B. During the period of mood disturbance, at least 3 of the
following symptoms have persisted (4 if the mood is only
irritable) and have been present to a significant degree.
 1. Inflated self-esteem and grandiosity
 2. Decreased need for sleep
 3. More talkative than usual or pressure to keep talking
 4. Flight of ideas or subjective experience that thoughts
are racing
 5. Distractibility
MOOD ELEVATION DISORDERS
6. Increase in goal-directed activity or psychomotor
agitation
 7. Excessive involvement in pleasurable activities which
have a high
 potential for painful consequences (unrestrained buying
sprees, sexual
 indiscretions, foolish business investments)
– C. Mood disturbance sufficiently severe to cause marked
impairment in
 occupational functioning or in usual social activities or
relationships with
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others, or to necessitate hospitalization to prevent harm to
self or others.
Hypomanic episode
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By definition, the hypomanic episode is less severe
than the full manic episode. DSM 
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
IV has attempted to quantify this difference. It is unclear whether
this distinction is helpful.
Rather than being present for 1 week, the diagnostic criteria state
that hypomania need be present for only 4 days. The need for 3 or
4 of 7 listed symptoms remains unchanged.
The main difference is that: “ The episode is not severe enough to
cause marked impairment in social or occupational functioning, or
to necessitate hospitalization, and there are no psychotic
symptoms ”.
Cyclothymic disorder
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The DSM-IV diagnostic criteria are that over a
period of 2 years there have been numerous
episodes of hypomanic symptoms and numerous
episodes of depressive symptoms. Further, during
this time it is not been possible to make a
diagnosis of major depressive episode, manic
episode or mixed mood state.