mood disorders. #1 cause of suicide #1 disorder seen in outpatient
TRANSCRIPT
Mood DisordersMood Disorders
#1 cause of suicide#1 cause of suicide #1 Disorder seen in outpatient#1 Disorder seen in outpatient
Mood DisordersMood Disorders
UnipolarUnipolar– Major DepressionMajor Depression– DysthymiaDysthymia– Depressive Disorder NOSDepressive Disorder NOS
BipolarBipolar– CyclothymiaCyclothymia– Bipolar IBipolar I– Bipolar IIBipolar II– Bipolar disorder NOSBipolar disorder NOS
Substance induced mood disorderSubstance induced mood disorder Mood disorder due to a medical conditionMood disorder due to a medical condition Mood Disorder NOSMood Disorder NOS
Major DepressionMajor Depression
Must have Must have – 1) Depressed Mood -dysphoria1) Depressed Mood -dysphoria
OrOr– 2) Loss of Interest or Pleasure in almost all activities-anhedonia2) Loss of Interest or Pleasure in almost all activities-anhedonia
Other symptoms (3-4)Other symptoms (3-4) Biological/Vegetative-Appetite, sleep, psychomotor, Biological/Vegetative-Appetite, sleep, psychomotor,
fatigue, libidofatigue, libido Psychological-concentration, neg thought, decision Psychological-concentration, neg thought, decision
making, guilt, low self esteem, hopeless, SImaking, guilt, low self esteem, hopeless, SI
Nearly every day for 2 weeksNearly every day for 2 weeks
Marked impairment in FunctioningMarked impairment in Functioning
Major DepressionMajor Depression
Diagnosis is not made if:Diagnosis is not made if:– Symptoms meet criteria for Mixed episode Symptoms meet criteria for Mixed episode
(symptoms of mania and major depression (symptoms of mania and major depression occurring nearly every day for at least a week)occurring nearly every day for at least a week)
– No functional impairment existsNo functional impairment exists– Symptoms are direct physiological effects of a Symptoms are direct physiological effects of a
medical condition or substance inducedmedical condition or substance induced– Symptoms are better accounted for by Symptoms are better accounted for by
BereavementBereavement
Major Depression PresentationMajor Depression Presentation
Tearful, flat affectTearful, flat affect IrritabilityIrritability RuminationsRuminations Psychomotor changesPsychomotor changes FatigueFatigue Sense of Sense of
worthlessness/guiltworthlessness/guilt Worry over physical healthWorry over physical health Complaints of painComplaints of pain Suicidal IdeationsSuicidal Ideations Psychotic FeaturesPsychotic Features
Relational difficultiesRelational difficulties Poor/increased appetitePoor/increased appetite Sleep problemsSleep problems Impaired ability to think, Impaired ability to think,
concentrate, make concentrate, make decisions, recalldecisions, recall
Reduced libido and sexual Reduced libido and sexual functioningfunctioning
Substance abuseSubstance abuse Increased use of medical Increased use of medical
servicesservices
Cultural PresentationsCultural Presentations
May present more somaticallyMay present more somatically Latino/Mediterranean: Nerves, headachesLatino/Mediterranean: Nerves, headaches Chinese/Asian: weakness, tired, imbalanceChinese/Asian: weakness, tired, imbalance Middle Eastern: Problems of the “heart”Middle Eastern: Problems of the “heart” Hopi: Heart BrokenHopi: Heart Broken Nigeria and Ghana: “worms crawling all over the Nigeria and Ghana: “worms crawling all over the
head”head” Amish, Kenya and Rwanda-virtually unheard ofAmish, Kenya and Rwanda-virtually unheard of
Age Related PresentationsAge Related Presentations
Children: somatic, irritability, social Children: somatic, irritability, social withdrawalwithdrawal
Not common in children: psychomotor Not common in children: psychomotor retardation, hypersomnia and delusionsretardation, hypersomnia and delusions
Adolescents: Irritability, behavioral problemsAdolescents: Irritability, behavioral problems Elderly: disorientation, memory loss, Elderly: disorientation, memory loss,
distractibilitydistractibility
Major DepressionMajor Depression
Twice as frequent in women than menTwice as frequent in women than men Occurs over the life spanOccurs over the life span Genetic links important to assessGenetic links important to assess
DysthymiaDysthymia
Does not meet criteria for Major DepressionDoes not meet criteria for Major Depression At least 2 years with no normal mood longer than At least 2 years with no normal mood longer than
2 months2 months No Manic, Mixed, Hypomanic, Cyclothymic No Manic, Mixed, Hypomanic, Cyclothymic
episode ever experiencedepisode ever experienced No psychotic symptomsNo psychotic symptoms Does not meet Major Depression Criteria during Does not meet Major Depression Criteria during
the first two yearsthe first two years Not due to medical or substanceNot due to medical or substance
DysthymiaDysthymia
Chronically depressed mood for 2 yrs, more Chronically depressed mood for 2 yrs, more days than notdays than not
An additional two symptoms: appetite, sleep An additional two symptoms: appetite, sleep disturbance, fatigue, low self-esteem, poor disturbance, fatigue, low self-esteem, poor concentration or hopelessnessconcentration or hopelessness
Some clinically significant distress or Some clinically significant distress or impairment in functioningimpairment in functioning
SpecifiesSpecifies
Early onset: Before 21 (More likely to Early onset: Before 21 (More likely to develop Major Depressive Disorder)develop Major Depressive Disorder)
Late Onset: Onset 21 yrs or laterLate Onset: Onset 21 yrs or later With Atypical Features: Reactive mood plus With Atypical Features: Reactive mood plus
2 (increased appetite, hypersomnia, 2 (increased appetite, hypersomnia, arms/legs feel heavy, rejection sensitivity arms/legs feel heavy, rejection sensitivity even when not depressed)even when not depressed)
Dysthymic PresentationDysthymic Presentation
Feelings of inadequacyFeelings of inadequacy General loss of interest or pleasureGeneral loss of interest or pleasure Social withdrawalSocial withdrawal Feelings of guilt of brooding over the pastFeelings of guilt of brooding over the past Irritability/angerIrritability/anger Decreased activityDecreased activity Vegetative symptoms are less commonVegetative symptoms are less common
DysthymiaDysthymia
Women 2-3 times more likely than menWomen 2-3 times more likely than men Equally in male and female childrenEqually in male and female children Early onset and chronic course Early onset and chronic course Genetically linked to Major depression and Genetically linked to Major depression and
DysthymiaDysthymia
CyclothymiaCyclothymia
Hypomania and DysphoriaHypomania and Dysphoria At least 2 yearsAt least 2 years No normal mood for over 2 months at a timeNo normal mood for over 2 months at a time Does not meet criteria for Major Depressive DisorderDoes not meet criteria for Major Depressive Disorder No Mania, Mixed or Major Depression during the first 2 No Mania, Mixed or Major Depression during the first 2
yearsyears Not due to psychosisNot due to psychosis Not due to substance or medicalNot due to substance or medical Clinically significant distress or impairment of functioningClinically significant distress or impairment of functioning
CyclothymiaCyclothymia
Chronic, fluctuating moodChronic, fluctuating mood Symptoms do not have to meet criteria for Symptoms do not have to meet criteria for
hypomania or dysthymia, but must hypomania or dysthymia, but must demonstrate symptoms similar to both demonstrate symptoms similar to both disordersdisorders
CyclothymiaCyclothymia
Onset: adolescents and early adulthoodOnset: adolescents and early adulthood Equally common in men and womenEqually common in men and women Chronic courseChronic course Genetic link to other mood disorders Genetic link to other mood disorders
(especially Bipolar I)(especially Bipolar I)
Bipolar IBipolar I
One or more Manic episode or mixed One or more Manic episode or mixed episodeepisode
Often they have Major Depression Episodes Often they have Major Depression Episodes as wellas well
Specifiers are the same as for Bipolar II and Specifiers are the same as for Bipolar II and will be covered in the next sectionwill be covered in the next section
Criteria needed for Manic DisorderCriteria needed for Manic Disorder
Distinct period (at least one week) of elevated, Distinct period (at least one week) of elevated, expansive or irritable moodexpansive or irritable mood
Three or more: grandiosity, sleep (3 hrs), Three or more: grandiosity, sleep (3 hrs), pressured speech, thoughts racing, distractibility, pressured speech, thoughts racing, distractibility, increased goal directed activity (planning and increased goal directed activity (planning and participating in several activities) or psychomotor participating in several activities) or psychomotor agitation, excessive involvement in high risk agitation, excessive involvement in high risk pleasurable activitiespleasurable activities
Symptoms do not meet criteria for Mixed disorderSymptoms do not meet criteria for Mixed disorder Not medical/substance inducedNot medical/substance induced Marked impairment in functioningMarked impairment in functioning
Manic PresentationManic Presentation
Do not recognize they are ill and resist treatmentDo not recognize they are ill and resist treatment Poor judgment and impulsivity combined with Poor judgment and impulsivity combined with
accelerated activity are likely to lead to behaviors accelerated activity are likely to lead to behaviors that will have neg. consequencesthat will have neg. consequences
After the episode there is usually regret for After the episode there is usually regret for behaviorsbehaviors
Mood is fun, irritable, angry, even depressed at Mood is fun, irritable, angry, even depressed at times. If the depression meets criteria for major times. If the depression meets criteria for major depression and occurs every day with mania-then depression and occurs every day with mania-then a mixed episode is diagnoseda mixed episode is diagnosed
Adolescents and ManiaAdolescents and Mania
Adolescents with mania are likely to have Adolescents with mania are likely to have psychotic features, school truancy and psychotic features, school truancy and failure, antisocial behaviors, and substance failure, antisocial behaviors, and substance abuse. They may have long standing abuse. They may have long standing behavioral problems before their first manic behavioral problems before their first manic episodeepisode
Course of ManiaCourse of Mania
Onset: early 20’s is average, but may begin Onset: early 20’s is average, but may begin at other timesat other times
Usually last a few weeks to several months Usually last a few weeks to several months and begin and end abruptlyand begin and end abruptly
Mixed episodeMixed episode
At least one week in which criteria for Mania and At least one week in which criteria for Mania and Major Depression are both metMajor Depression are both met
Presentation includes rapid altering of sadness, Presentation includes rapid altering of sadness, irritability, and euphoria. Individuals are often irritability, and euphoria. Individuals are often agitated, insomnic, have appetite changes, agitated, insomnic, have appetite changes, psychotic features (disorganized thinking and psychotic features (disorganized thinking and behavior) and suicidal ideationsbehavior) and suicidal ideations
Must cause marked impairment in functioning, Must cause marked impairment in functioning, have psychotic features, or require hospitalizationhave psychotic features, or require hospitalization
Not due to substances, Medical, of medicinesNot due to substances, Medical, of medicines
Bipolar IIBipolar II
Hypomania and Major DepressionHypomania and Major Depression No history of mania or mixed episodesNo history of mania or mixed episodes Not caused by substance or medicalNot caused by substance or medical Impairment in functioningImpairment in functioning
Hypomanic Episode Criteria needed Hypomanic Episode Criteria needed for Bipolar IIfor Bipolar II
Elevated, expansive, or irritable mood lasting 4 Elevated, expansive, or irritable mood lasting 4 daysdays
Three or more: grandiosity, sleep (3 hrs), Three or more: grandiosity, sleep (3 hrs), pressured speech, thoughts racing, distractibility, pressured speech, thoughts racing, distractibility, increased goal directed activity (planning and increased goal directed activity (planning and participating in several activities) or psychomotor participating in several activities) or psychomotor agitation, excessive involvement in high risk agitation, excessive involvement in high risk pleasurable activitiespleasurable activities
Mood and change noticeable by othersMood and change noticeable by others No severe functioning difficultiesNo severe functioning difficulties No medical/substance causeNo medical/substance cause
Specifiers for Bipolar I and IISpecifiers for Bipolar I and II
Hypomanic (current or most recent episode)Hypomanic (current or most recent episode) Depressed (current or most recent episode)Depressed (current or most recent episode)
– Current major depressive episodeCurrent major depressive episode Mild, moderate or severe without psychotic features Mild, moderate or severe without psychotic features
or with psychotic featuresor with psychotic features ChronicChronic With catatonic featuresWith catatonic features With melancholic featuresWith melancholic features With atypical featuresWith atypical features With postpartum onsetWith postpartum onset
Specifiers for Bipolar I and IISpecifiers for Bipolar I and II
If criteria for Major Depressive Disorder or If criteria for Major Depressive Disorder or Hypomanic Disorder are not metHypomanic Disorder are not met– In partial remission, In full remissionIn partial remission, In full remission– ChronicChronic– With Catatonic featuresWith Catatonic features– With Melancholic featuresWith Melancholic features– With Atypical featuresWith Atypical features– With postpartum onsetWith postpartum onset
Specifiers to indicate pattern or Specifiers to indicate pattern or frequency of episodes of Bipolar I frequency of episodes of Bipolar I
and IIand II Longitudinal Course Specifiers (with or Longitudinal Course Specifiers (with or
without interepisode recovery)without interepisode recovery) With Seasonal PatternWith Seasonal Pattern With Rapid CyclingWith Rapid Cycling
Additional ConsiderationsAdditional Considerations
If hypomanic episode occurs after age 40, If hypomanic episode occurs after age 40, strongly explore medical possibilitiesstrongly explore medical possibilities
Women with Bipolar II are more likely to Women with Bipolar II are more likely to have postpartum symptomshave postpartum symptoms
Genetic transmission Genetic transmission
Mood Disorder due to a General Mood Disorder due to a General Medical ConditionMedical Condition
Mood is the direct physiological effect of a medical Mood is the direct physiological effect of a medical conditioncondition
SubtypeSubtype– With depressive featuresWith depressive features– With major depressive-like episodeWith major depressive-like episode– With manic FeaturesWith manic Features– With mixed featuresWith mixed featuresImpairment in functioningImpairment in functioning
Note the type of medical condition on Axis I (due to …) and on Axis III Note the type of medical condition on Axis I (due to …) and on Axis III ICD-9-CM codeICD-9-CM code
GIVE HANDOUTGIVE HANDOUT
Substance Induced Mood DisorderSubstance Induced Mood Disorder
Direct physiological effect of a substanceDirect physiological effect of a substance Only made when symptoms exceed those Only made when symptoms exceed those
expected from intoxication or withdrawal from the expected from intoxication or withdrawal from the substance (otherwise dx substance intoxication or substance (otherwise dx substance intoxication or substance withdrawal)substance withdrawal)
Subtypes: w/ depressed features, w/ manic Subtypes: w/ depressed features, w/ manic features, w/ mixed featuresfeatures, w/ mixed features
With onset during intoxication, with onset during With onset during intoxication, with onset during withdrawalwithdrawal
GIVE HANDOUTGIVE HANDOUT
Mood Disorder NOSMood Disorder NOS
Mood Disorder does not meet any of the Mood Disorder does not meet any of the criteria discussed and there is not enough criteria discussed and there is not enough evidence to diagnose Bipolar NOS or evidence to diagnose Bipolar NOS or Depressive Disorder NOSDepressive Disorder NOS
Specifiers are noted with numbersSpecifiers are noted with numbers
.x1- mild-minimum symptoms met, capacity to function with .x1- mild-minimum symptoms met, capacity to function with extreme effortextreme effort
.x2-moderate-between mild and severe.x2-moderate-between mild and severe .x3-severe without psychotic features- severe impairment .x3-severe without psychotic features- severe impairment
and most symptomsand most symptoms .x4-severe with psychotic features- delusions or .x4-severe with psychotic features- delusions or
hallucinations (mood-congruent vs mood incongruent)hallucinations (mood-congruent vs mood incongruent) .x5- in partial remission: 1)reduced symptoms or 2) no .x5- in partial remission: 1)reduced symptoms or 2) no
symptoms for less than 2 monthssymptoms for less than 2 months .x6- in full remission: 2 months without symptoms.x6- in full remission: 2 months without symptoms .x0 unspecified.x0 unspecified
SpecifiersSpecifiers
Chronic- most recent type occurring continuously Chronic- most recent type occurring continuously for 2 yearsfor 2 years
Catatonic- motor immobility or stuporCatatonic- motor immobility or stupor– Excessive motor activity without purposeExcessive motor activity without purpose– Extreme negativism (motiveless resistence to instruction Extreme negativism (motiveless resistence to instruction
or rigid posturing) or mutismor rigid posturing) or mutism– Posturing, stereotyped movement and mannerismsPosturing, stereotyped movement and mannerisms– Echolalia (repetition of words-parrotlike) or echopraxia Echolalia (repetition of words-parrotlike) or echopraxia
(repetitve movements of another person)(repetitve movements of another person)
SpecifiersSpecifiers
Melancholic Features:Melancholic Features:– Loss of pleasure or lack of reactivity to positive Loss of pleasure or lack of reactivity to positive
events and events and – 3 or more symptoms: depression worse in am, 3 or more symptoms: depression worse in am,
distinctly depressed mood, early morning distinctly depressed mood, early morning awakening, marked psychomotor symptoms, awakening, marked psychomotor symptoms, significant weightloss, excessive guiltsignificant weightloss, excessive guilt
Atypical FeaturesAtypical Features
Mood ReactivityMood Reactivity Two or more:Two or more:
– Weight gain and increased appetiteWeight gain and increased appetite– HypersomniaHypersomnia– Leaden paralysisLeaden paralysis– Longstanding interpersonal sensitivity (not Longstanding interpersonal sensitivity (not
limited to mood disturbance) that results in limited to mood disturbance) that results in functional impairmentfunctional impairment
Not with Melancholic or catatonic featuresNot with Melancholic or catatonic features
Postpartum onsetPostpartum onset– Onset within 4 weeks postpartumOnset within 4 weeks postpartum
Recurrent episode specifiersRecurrent episode specifiers
-- With/without interepisode recovery-- With/without interepisode recovery
--Seasonal pattern--Seasonal pattern
--Rapid Cycling: At least four episodes in 12 --Rapid Cycling: At least four episodes in 12 months months
Differential DiagnosisDifferential Diagnosis
Uncomplicated BereavementUncomplicated Bereavement Acting out in adolescents: reduce acting out Acting out in adolescents: reduce acting out
(defense), depression may show itself(defense), depression may show itself Schizophrenia and schizodisorders: Mood Schizophrenia and schizodisorders: Mood
disorders can have psychotic symptomsdisorders can have psychotic symptoms Adjustment disorders with depressed moodAdjustment disorders with depressed mood
EtiologyEtiology
Family hx and genetics: depression, alcoholism, Family hx and genetics: depression, alcoholism, antisocialism, suicide attemptsantisocialism, suicide attempts
Neurological: serotonin, norepinephrine, dopamineNeurological: serotonin, norepinephrine, dopamine Psychosocial: loss of parent in 1Psychosocial: loss of parent in 1stst 5 years or father 5 years or father
from 10-14, low social support, abuse hx, from 10-14, low social support, abuse hx, predisposition & stress, personality factorspredisposition & stress, personality factors
Neuroendocrine: hormonal, adrenal (cortisol), Neuroendocrine: hormonal, adrenal (cortisol), thyroidthyroid
Sleep ProblemsSleep Problems
Medical TreatmentsMedical Treatments
ECTECT TCA’sTCA’s SSRIsSSRIs SNRIs and other atypical drugsSNRIs and other atypical drugs MAOIsMAOIs AntipsychoticsAntipsychotics LithiumLithium anticonvulsantsanticonvulsants
Psychological Treatments proven by Psychological Treatments proven by ResearchResearch
CBTCBT Interpersonal TherapyInterpersonal Therapy
Examples of What I doExamples of What I do
Suicide Assessment/Homicide AssessmentSuicide Assessment/Homicide Assessment Obtain blood workObtain blood work Close examination of symptom duration, frequency, onset, Close examination of symptom duration, frequency, onset,
family hx (genetics), vegetative symptoms, cognitive family hx (genetics), vegetative symptoms, cognitive interference, functional interference,and level of subjective interference, functional interference,and level of subjective distress to assess need for med evaluationdistress to assess need for med evaluation
Work with psychiatrist to ensure sleepWork with psychiatrist to ensure sleep Validate subjective experience and give sick roleValidate subjective experience and give sick role Explore triggers (ie interpersonal, stress, etc)Explore triggers (ie interpersonal, stress, etc) Explore strengths and encourage what has worked in the Explore strengths and encourage what has worked in the
pastpast
Examples of What I doExamples of What I do
Assess for cognitive and emotional regulation Assess for cognitive and emotional regulation skills. Build up areas of weakness to help in daily skills. Build up areas of weakness to help in daily functioning. Develop coping options for when functioning. Develop coping options for when episodes occurepisodes occur
Educate about disorder and med complianceEducate about disorder and med compliance Once daily functioning is more stable and begin Once daily functioning is more stable and begin
working on past issues to resolve and relearn working on past issues to resolve and relearn ways to interact with the environment and othersways to interact with the environment and others