Transcript MOOD DISORDERS

MOOD DISORDERS
Epidemiology
Sex: MDD F:M = 2:1
BID
F=M
 Age: onset - BID is earlier (30 yo)
than MDD (40yo)
 Marital Status: MDD - no close
interpersonal relationships, divorced,
separated
BID - single/divorced > married
 SE & Cultural Considerations

Etiology
1.
Biological Factors: abN in biogenic
amine metabolites (5-HIAA, HVA,
MHPG)
Biogenic Amines - NE, 5HT, DA, GABA
2. Neuroendocrine regulations
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Hypothalamus
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3.
Adrenal axis
Thyroid axis
Growth hormone
3.
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8.
Sleep Abnormalities - EEG abN
Kindling
Circadian Rhythm
Neuroimmune Regulations
Brain Imaging - CT scan, MRI
Neuroanatomical Considerations - limbic
system, basal ganglia, hypothalamus
2.
Genetic Factors - BID > MDD
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3.
Family Studies
Adoption Studies
Twin Studies
Psychosocial Factors
1.
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3.
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5.
Life events & Environmental stress
Premorbid Personality Factors
Psychoanalytic & Psychodynamic Factors
Learned Helplessness
Cognitive Theory
Diagnosis
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Major Depressive Disorder
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Depressed mood
Loss of interest or pleasure
Weight loss or gain
Insomnia/hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or inappropriate guilt
Diminished ability to think or concentrate
Recurrent thoughts of death
Sxs cause significant distress or impairment
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Manic Episode
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Elevated, expansive, or irritable mood
Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative
Flights if ideas
Distractibility
Psychomotor agitation
Excessive involvement in pleasurable
activities
Clinical Features
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Depressive Episodes
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Depressed mood: feel blue, sad, hopeless,
worthless
– Agonizing emotional pain
– 2/3 contemplate suicide
– 10 - 15% commit suicide
– 97% - reduced energy
– 80% - sleep disturbance
– Decreased appetite
– 90% - anxiety
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Atypical Features
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Hysteroid Dysphoria
– Increased appetite
– Weight gain
– Hypersomnia
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Depression in Children and
Adolescents
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School phobia
Poor academic performance
Substance abuse
Antisocial behavior
Sexual promiscuity
Truancy
Running away
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Depression in the Elderly
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More common - 25-50%
– More somatic complaints
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Manic Episodes
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Elevated, expansive, irritable mood
Infectious
Disinhibited
Impulsive
Preoccupied by religious, political,
financial, sexual or persecutory ideas
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Manic in Adolescents
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Misdiagnosed as antisocial PD or
schizophrenia
– Psychosis, substance abuse, suicide
attempts, academic problems, somatic
complaints, irritability
Co-existing Diagnosis
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4.
Anxiety
Alcohol dependence
Other substance-related disorder
Medical conditions
Mental Status Examination
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Depressive Episodes
General Description - retardation,
agitation
2. MAF - depression
3. Speech - decreased rate and volume
4. Perceptual Disturbances
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With perceptual disturbances
Psychotic depression
Mood-congruent
Mood-incongruent
5. Thought - negative view of the world and
themselves
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Content - loss, suicide, guilt, death
Thought blocking
6. Sensorium and Cognition
Memory: 50-75% depressive dementia
Impaired concentration & forgetfulness
7. Impulse Control
10-15% - complete suicide
2/3 cases - suicide ideation
Paradoxical suicide
8. Judgment and Insight
excessive insight
9. Reliability
poor
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Manic Episodes
General Description - excited, talkative,
hyperactive
2. MAF - euphoric, irritable, angry, hostile,
labile
3. Speech - disturbed, loud, rapid,
pressured
4. Perceptual disturbances - 75%
delusional
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5. Thought
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Content: self-confidence, selfaggrandizement
Form: looseness of association, flight of
ideas, word salad, neologisms
Cognitive function: unrestrained, accelerated
flow of ideas
6. Sensorium and Cognition
orientation and memory intact
7. Impulse Control - 75% assaultive and
threatening
attempt suicide and homicide
8. Judgment and Insight
impaired judgment - hallmark
little insighht
9. Reliability
notoriously unreliable
lying and deceit
Differential Diagnosis
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MDD
1.
2.
Medical Disorders - medications, neurological
conditions
Mental Disorders
1.
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3.
4.
Mood DO due to General Medical Condition
Substance-Induced Mood DO
Other Mental DO - SRD, psychotic DO, eating
DO, adjustment DO, anxiety DO, somatoform
DO
Uncomplicated Bereavement
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BID
Medical DO
2. Mental DO - BIID, cyclothymia, Mood
DO due to General Medical Condition,
Substance-Induced Manic episode,
Borderline PD, Narcissistic, Histrionic,
Antisocial PDs, Schizophrenia
1.
Course and Prognosis
Chronic, tend to have relapses
 MDD Course
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Onset: 50% before age 40 years
Duration: untreated
6-13 months
treated
3 months
Development of manic episodes: 5-10%
with initial diagnosis MDD have manic
episode 6-10 years after
Mean age of switch = 32 years old
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Prognosis: chronic, tend to relapse
 Indicators:
GOOD - mild episodes, (-)
psychosis, short hospital stay, (+) social
support, (-) comorbidity, advanced age of
onset
POOR - co-existing dysthymic DO,
abuse of alcohol and other substances,
anxiety DO sxs, hx of more than one episode
of depression
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BID Course
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Most often starts with depression
– Recurring disorder
– Manic episode has rapid onset
– Prognosis: poorer prognosis than MDD
 40-50%
have 2nd manic episode within 2
years
 50-60% are controlled with lithium
 Indicators:
GOOD - short duration, advanced
stage of onset, few suicidal attempts, few
coexisting psych or medical problems
POOR - poor occupational status,
alcohol dependence, (+) psychosis,
depressive features, males
Treatment
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GOALS
Safety of the patient
2. Complete diagnostic evaluation
3. Treatment plan
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Treatment must reduce the number
and severity of the stressors in
patients’ lives
Hospitalization
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Indications: prognostic procedures
risk of suicide and homicide
grossly regressed
Psychotherapy
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Short-term psychotherapy: cognitive,
interpersonal, bahavior
3. Pharmacotherapy
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MDD: 3-4 weeks
principal indication: major depressive episode
Patient education
Alternatives to Drug Therapy: ECT and
phototherapy
ECT: unresponsive to pharmacotherapy
cannot tolerate pharmacotherapy
severe situations that rapid improvement is
needed
PHOTOTHERAPY: with seasonal pattern; mild
Guidelines: Dosage of antidepressant
should be raised to the maximum
recommended level and maintained at
that level for at least 4 weeks.
 Duration and Prophylaxis:
Antidepressant treatment should be
maintained for at least 6 months.
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BID: lithium, carbamazepine, valproate
 Lithium:
standard treatment
SE: renal, nervous, metabolic, GI, derma,
thyroid
 Anticonvulsants: carbamazepine, valproate
 Other agents: clonazepam, clonidine,
clozapine, verapamil
Dysthymic Disorder
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EPIDEMIOLOGY
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Common; 3-5% of all persons
– Females (less than 65yo) > men
– Frequently coexists with other mental Dos
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ETIOLOGY
1.
Biological Factors
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Sleep studies
Neuroendocrine axis
Psychosocial Factors
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Faulty personal and ego development
Defense mechanism: reaction formation
Low self-esteem, anhedonia, introversion
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DIAGNOSIS
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Depressed mood most of the time for at
least 2 years
– (-) manic or hypomanic episodes
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CLINICAL FEATURES
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Chronic
– Severity of depressive symptoms is
generally less
– Sarcastic, nihilistic, brooding, demanding,
complaining
– (-) psychotic symptoms
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Associated symptoms:
 Changes
in appetite and sleep patterns
 Decreased sexual drive
 Low self-esteem
 Loss of energy
 Psychomotor retardation
 Pessimism, hopelessness, helplessness
 Social impairment
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CO-EXISTING DIAGNOSIS
Double Depression - poorer prognosis
2. Alcohol and other substance abuse alcohol, stimulants, MJ
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DIFFERENTIAL DIAGNOSIS
Minor Depressive DO
2. Recurrent Brief Depressive DO
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COURSE AND PROGNOSIS
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50%: insidious onset before age 25 years
– 25%: progressed to MDD
– 15%: BIID
– <5%: BID
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TREATMENT
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Pharmacotherapy + cognitive/behavior tx
Cyclothymic Disorder
Mild Bipolar II Disorder
 Hypomania and mild depression
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EPIDEMIOLOGY
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3-10% of all psychiatric patients
1% lifetime prevalence
Frequently co-exists with Borderline PD
F:M = 3:2
Onset between 15-25 years old (50-75%)
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ETIOLOGY
1.
Biological Factors
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Genetic: 30% (+) history of BID
Psychosocial Factors
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Trauma and fixation during oral stage
Freud: ego attempts to overcome a harsh
and punitive superego
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DIAGNOSIS
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CLINICAL FEATURES
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Symptoms at least 2 years
Less severe symptoms of BID
Hypomanic symptoms
Mixed symptoms with marked irritability
Shorter cycles
Substance Abuse: to self-medicate or
to achieve further stimulation
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DIFFERENTIAL DIAGNOSIS
Medical and Substance-Related causes
of depression and mania
2. Borderline, antisocial, histrionic,
narcissistic PDs
3. ADHD
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COURSE AND PROGNOSIS
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Insidious onset; teens or early 20’s
1/3 go to major mood DO, most often
BIID
TREATMENT
Biological tx: antimanic - LiCO3
2. Psychosocial tx: directed towards
patients’ insight and coping mechanisms
for their mood swings
1.