Transcript Affective disorders

Affective (Mood) Disorders
Basal characteristics
-Mood disorders are very common
-Life prevalence is up to 20 %, and they have a high level of morbidity
and mortality as well as an immense impact on disabilities worldwide
-The fundamental disturbance is a change in mood or affect, usually to
depression (with or without associated anxiety) or to elation (mania or
hypomania).
-The mood change is usually accompanied by a change in the overall
level of activity.
-Most of these disorders tend to be recurrent, and the onset of
individual episodes is often related to stressful events or situations.
Classification of Mood Disorders
(ICD X)
• F30 Manic Episode
• F31 Bipolar Affective Disorder
• F32 Depressive Episode
• F33 Recurrent Depressive Disorder
• F34 Persistent Mood Disorders
• Cyklothymia
• Dysthymia
Unipolar vs. Bipolar Disorder
Elevated
Mood
Bipolar
Depressed
Mood
Elevated
Mood
Unipolar
Depressed
Mood
Classification of Depression ICD 10
F32 Depressive Episode
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–
–
–
Mild (without vs. with somatic symptoms)
Moderate (without vs. with somatic symptoms)
Severe without psychotic symptoms
Severe with psychotic symptoms
F33 Recurrent Depressive Disorder
–
–
–
–
–
Current episode mild (without vs. with somatic symptoms)
Current episode moderate (without vs. with somatic symptoms)
Current episode severe without psychotic symptoms
Current episode severe with psychotic symptoms
Currently in remission
Depressive disorder - epidemiology
• Prevalence (the total number of cases in the population, divided by the number of individuals in the population )
5-10% in females, 2-3% in males
• Lifetime risk (The risk of developing a disease during ones lifetime )
in females 10–25%, in males 5–20%
• 15% of depressed patients commit suicide; generally
increased mortality rate
Depressive episode ICD X
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•
basal (typical) symptoms: depressed mood, loss of interest and low level of
energy ≥ 2 weeks
(a) reduced concentration and attention;
(b) reduced self-esteem and self-confidence;
(c) ideas of guilt and unworthiness (even in a mild type of episode);
(d) bleak and pessimistic views of the future;
(e) ideas or acts of self-harm or suicide;
(f) disturbed sleep;
(g) diminished appetite.
Somatic symptoms (Somatic Syndrome)
• Some of the above symptoms may be marked and develop
characteristic features that are widely regarded as having special
clinical significance.
• loss of interest or pleasure in activities that are normally enjoyable;
• lack of emotional reactivity to normally pleasurable surroundings and
events
• waking in the morning 2 hours or more before the usual time
• depression worse in the morning;
• objective evidence of definite psychomotor retardation or agitation
• marked loss of appetite
• weight loss (5%or more of body weight in the past month)
• marked loss of libido.
Mild, moderate, severe episode of depression
• mild – 2 and more symptoms from basal 3 + at least 2 additional symptoms
• moderate - 2 symptoms from basal 3 + at least 3 additional symptoms
• severe - all symptoms from basal 3 + at least 4 additional symptoms in in
severe form
• severe with psychotic symptoms - a severe depressive episode in which
delusions, hallucinations, or depressive stupor are present. The delusions
usually involve ideas of sin, poverty, or imminent disasters, responsibility.
Auditory or olfactory hallucinations are usually of defamatory or accusatory
voices or of rotting filth or decomposing flesh. Severe psychomotor
retardation may progress to stupor. If required, delusions or hallucinations
may be specified as mood-congruent or mood-incongruent
F 33 Recurrent Depressive Disorder
• Repeated depressive episodes without history of separate
episodes of mania (previously there was at least one episode
of depression lasting minimally 2 weeks and was separated
from the current one by the period of 2 months without
symptoms)
• Current episode: mild, moderate, severe with or without
psychotic symptoms, in remission
Cognitive behavioral model of
depression
Early childhood experiences
(conditional acceptance, conditional self-acceptance)
Creation of dysfunctional cognitive schemes
(”I must succeed in everything“, “ If not perfect, it’s worthless“, etc.)
Critical events
(failures and increased expectations and demands 6 – 12 months prior onset of depression)
Negative automatic thoughts
(cognitive negative triad: negative self-assessment, negative assessment of external events, negative expectations of the
future)
Symptoms of depression
physical
affective
cognitive
behavioral
Možný a Praško, 1999
Differential diagnosis
Alcohol (30%), other
psychoactive substances
Other psychiatric dg.: anxiety
disorders, schizophrenia,
eating disorders,
somatoform dis, personality
dis., etc.
Cardiovascular disorders
(myocardial infarct 4065%); surgery,
transplantation
Endocrinological disorders,
metabolic disorders
(diabetes, deficit B12,
thyreod., parathyr., kidney
dis....)
Others: tumors, infections, fatigue sy...
Neurological disorders:
epilepsy (30-70%), Parkinson’s
dis. (4-70%), Huntington’s dis.
(37-43%), ictus (40-65%),
multiple sclerosis (37-54%),
dementia – Alzheimer’s d. (3040%), tics, Tourette’s, tumors,
traumas, migrains, Wilson’s dis.,
muscular dystrophy, etc.
Drugs potentially inducing depression
Psychotropics and substances
Alcohol (30%); reserpine (5-20%); cocain; marihuana; psychostimulants
Hormonal drugs
Anabolics (12%); estrogene contraception (5-20%); corticosteroids (5%);
antagonists of gonadoliberine; ACTH (5%); progesterone, tamoxifene
Cardiovascular drugs
Propranolol (1-20%); alpha-methyldopa (10%); clonidine (1,5%); inhibitors of
angiotenzine converting enzyme, Ca channel blockers; cinarizine
Antipsychotics
Typical antidopaminergic antipsychotics in long-term treatment (10%)
Antiepileptics
Phenobarbital; phenytoin; topiramate; vigabatrine
Antimigrain drugs
Flunarizin; sumatriptan
Antagonists of H2 receptors
Cimetidine
Antagonists H3 receptors
Ondansetrone
Benzodiazepines
Diazepam
Sedating hypnotics
Triazolam
Antihistaminics
Older drugs
Hypolipidemics
Antiparkinsonics
Nonsteroid antirevmatics
Chemoterapeutics of tumors
Interferones
+
Retinoides
Other common drugs
Anders, 2005
metoclopramid; tramadol; ofloxacin; baclofen
Course and prognosis
• Typical onset around age of 30´, earlier and late onset= increased risk of
recurrence
• Development during days to weeks, prodromes (anxiety, mild signs of
depression) can last longer (weeks to months)
• Untreated episode – 6-24 months, modern antidepressants have response
rates in the 65% range and response to treatment typically requires 2–6
weeks or more and about one-third of patients will become resistant
• Unfavorable prognosis: more severe symptoms at onset (?), comorbidity
of personality and organic disorders
Course and prognosis (cont. I)
• High risk of relapse during first 12 weeks of remission (25 % of
total relapses)
• Risk of subsequent episode is increased with number of past
episodes and with persistent sublinical symptoms
• With older age intervals between episode could be shorter
Likelihood of having another depressive
episode if you’ve had…
1 episode
50%
Major
Depressive
Episode
Major
Depressive
Episode
3 episodes
90%
2 episodes
70%
Major
Depressive
Episode
Major
Depressive
Episode
Major
Depressive
Episode
Major
Depressive
Episode
Maintenance treatment is fully indicated
Bipolar Disorder
• Also known as manic depression, a mental
illness that causes a person’s moods to
swing from extremely happy and
energized (mania) to extremely sad
(depression)
• Chronic illness; can be life-threatening
• Most often diagnosed in adolescence
Epidemiology of Bipolar Disorder
• Prevalence: 1% of population Adults = Adolescents
• Males = Females
• The first attack occurs most commonly between the ages
of 15 and 30 years
• Tends to be recurrent
• 22% of adolescents with completed suicides had bipolar
disorder
Classification of bipolar disorder ICD X
F30 Manic episode
– Hypomania
– Mania without psychotic symptoms
– Mania with psychotic symptoms
F31 Bipolar affective disorder
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–
–
–
Current episode hypomanic
Current episode manic without psychotic symptoms
Current episode manic with psychotic symptoms
Current episode mild or moderate depression (w/wo somatic
symptoms)
– Current episode severe depression (w/wo psychotic symptoms)
– Current episode mixed
– Currently in remission
F 30 Manic episode
• Hypomania = persistent mildly elevated mood, increased energy level,
feelings of satisfaction and high efficiency. (Increased sociability, talkative,
easiness, sexual energy, decreased need for sleep – but still without
severe impairment of social or working functioning); hallucinations or
delusions are absent, ≥ 4 days
• Mania = elevated mood not corresponding to the circumstances increased
energy level (hyperactivity, talkative, decreased sleep, food, event.
dehydration, lack of hygiene, distractibility, attention deficit), increased
self-esteem, self-evaluation, overconfidence, lack of social inhibition,
racing thoughts, word salad, aggressivity, sometimes delusions of
grandeur, hallucinations
• The episode should last for at least 1 week and should be severe enough
to disrupt ordinary work and social activities more or less completely.
The mood change should be accompanied by increased energy and
several of the symptoms referred to above (particularly pressure of
speech, decreased need for sleep, grandiosity, and excessive optimism).
Manic episode with psychotic symptoms
• The clinical picture is that of a more severe form of mania.
• Inflated self-esteem and grandiose ideas may develop into delusions, and
irritability and suspiciousness into delusions of persecution.
• In severe cases, grandiose or religious delusions of identity or role may be
prominent, and flight of ideas and pressure of speech may result in the
individual becoming incomprehensible.
• Severe and sustained physical activity and excitement may result in
aggression or violence, and neglect of eating, drinking, and personal
hygiene may result in dangerous states of dehydration and self-neglect. If
required, delusions or hallucinations can be specified as congruent or
incongruent with the mood.
Manic episode – differential diagnosis
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Diff. dg.:
physical illness (multiple sclerosis, brain tumor, Cushing)
psychoactive substance
hyperkinetic disorder in children
euthymia in chronic depression
hyperthyroidism and anorexia nervosa
early states of "agitated depression„
Schizophrenia vs mania with psychotic symptoms
incongruent with mood
Bipolar Depression
(Depressive episode of Bipolar disorder)
• 80% of patients exhibit significant suicidality
• Depressive episodes dominate course of bipolar disorder
(twice the amount of time as in mania)
• 25-30% of patients initially diagnosed with unipolar depression
subsequently have a manic or hypomanic episode
Bipolar disorder
• This disorder is characterized by repeated (i.e. at least two) episodes in
which the patient's mood and activity levels are significantly disturbed,
this disturbance consisting on some occasions of an elevation of mood
and increased energy and activity (mania or hypomania), and on others of
a lowering of mood and decreased energy and activity (depression).
• Characteristically, recovery is usually complete between episodes.
• Patients who suffer only from repeated episodes of mania are rare, and
resemble (in their family history, premorbid personality, age of onset, and
long-term prognosis) those who also have at least occasional episodes of
depression, such patients are classified as bipolar.
COMORBID DISORDERS
• Substance Abuse – Alcohol, Cocaine, THC
• Narcissistic PD, Borderline PD
• 20-30% OCD, Panic Disorder
More mixed and rapid cycling, poorer response to lithium, slower
time to recovery and higher number hospitalizations
Bipolar I Disorder (DSM-IV)
One or more
manic episode
Manic
or Mixed
Episode
OR
OR
Depressed and
manic episodes
Major
Depressive
Episode
Manic
or Mixed
Episode
Bipolar II Disorder (DSM-IV)
One or more
hypomanic episode
OR
OR
Hypomanic
Episode
Depressed and
hypomanic episodes
Major
Depressive
Episode
Hypomanic
Episode
Rapid cycling (≥ 4 episodes per year)
Long-term course: Zurich study
• 406 patients from 1959 -1991
• Median of evaluation age: 68
60
60
50
Jules Angst
40
% 30
20
16
16
8
10
0
Remission
Recurence Chronicity
Suicidium
F 34 Persistent mood disorder
Cyclothymia and Dysthymia
• Last 2 and more years, fluctuating severity, episodes are not
so striking to be diagnosed under previously mentioned
(closer to so called “neurotic depression”)
• Sometimes superimpose recurrent disorder, or single episode
(i.e.double depression)
• In DSM-IV dysthymia is among depressive disorders and
cyclothymia among bipolar disorders
F 34.0 Cyclothymia
• 2 years of instable mood, several episodes of insignificant depression or
hypomania
• If onset is between age of 30 to 50, then mostly follows affective episode
• Lifetime prevalence 0.4–1%, more frequent in females, family history of
mood disorders, alcohol, personality disorders (associal)
• Etiopatogenesis – similarly to bipolar significant contribution of biological
and genetic factors is presumed
• Course and prognosis: onset in adolescence, frequent hyperactivity in
childhood, insidious, chronic course, 15-50% develop into bipolar; 60%
stabilizes with lithium
F 34.1 Dysthymia
• 2 years of persistent or recurrent mild depressive
symptomatology (normal mood maximum several weeks)
• Lifetime prevalence: 3-6%, higher in females
• Etiopatogenesis: similar to depression – biological factors
(polysomnograph, genetics), psychosocial
• Course and prognosis: onset in childhood or adolescence,
insidious, very likely develop into severe depressive episode