Transcript 9 Affect disorders

Affect disorders. Mask depression. Epilepsy.
Etiology and pathogeny. Classification.
Epileptic psychoses. Patients with changes of
personality on epileptic type.
Lyudmyla T. Snovyda
SADNESS AND DEPRESSION
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Sadness
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
SADNESS AND DEPRESSION
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Grief
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.
SADNESS AND DEPRESSION
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Grief
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 individua l, who is distressed and
finds making decisions difficult, has a clear scrip t/ritual to follow.
Adhering to the ritual ensures no one is offended during this emotiona l
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 .
SADNESS AND DEPRESSION
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Grief
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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
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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 disorder s)
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.
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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 d isorders are diagnosed using batches or
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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
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severe than major depressive disorder and bipolar depression.
Major depressive episode
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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 ther e has been an
episode of mania (pathologi cal mood elevation) in the past..
Major depressive episode
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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
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 neurotransmi tter 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 31-42% . 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 i
nclude neurotic personality traits, low self-esteem, early onset anxiety, a
history of conduct disorder, substance misuse, adversity, interpersonal
difficulties, low parental warmth, childhood sexual abuse, low eduction,
lifetime trauma, low social support , divorce and stressful life events
Major depressive episode
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Aetiology
Heritability of depression is estimated to be in the range 31-42% . 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 i
nclude neurotic personality traits, low self-esteem, early onset anxiety, a
history of conduct disorder, substance misuse, 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 w as drawn that bipolar disorder
(formerly manic
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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
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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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Manic episode
The DSM-IV diagnostic criteria for a manic episo de:
– 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
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Manic episode
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
 others, or to necessitate hospitalization to prevent harm to self or
others.
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MOOD ELEVATION DISORDERS
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Hypomanic episode
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
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unchanged. The main difference is that: “ The episode is not severe enough
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to cause
marked impairment in social or occupational functioning, or to necessitate
MOOD ELEVATION DISORDERS
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Cyclothymic disorder
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.