MOOD DISORDERS (MD)
Mood is the subjective component of emotions.
Currently MD are restricted to disorders where changes of mood are the
dominating feature.
Brief fluctuations of mood between sadness and happiness in response to
events and circumstances is normal and require no treatment.
On the contrary, lack of emotions is abnormal.
Persistent mood changes downward (depression) and upward (mania) are
abnormal, and with additional symptoms, constitute disorders or
syndromes.
DEPRESSION:
The life time prevalence is 10-25% for women and 5-12% for men.
Symptoms of depressive disorders are grouped into psychological,
biological, cognitive, social, and motor symptoms.
Psychological symptoms
include low or irritable mood, lack
of enjoyment (inability to respond to pleasurable events, anhedonia), loss
of interest, and poor concentration.
Biological symptoms
include sleep disturbance (insomnia),
diurnal changes of mood (mood changes with time of day), and loss of
appetite, weight, and libido, amenorrhea and constipation.
Cognition is characterised by slowing of thought process, negative
thinking, preoccupation with self-blame and feeling of guilt and
worthlessness.
The past is regretted, the present is resented, and the future appears
hopeless.
The patient believes that nothing could be done to help him and there is
no use in trying.
At this stage of depression, feelings of hopelessness and helplessness
prevail and the risk of suicide is very high.
Social symptoms
present as gradual withdrawal from work and
social activities and reluctance to meet friends and relatives.
Motor symptoms
include tiredness, feeling of lack of energy,
sparse speech, and retardation of movements. In some patients, agitation
and restlessness replace retardation.
Additional symptoms
are obsessions, depersonalisation, and in
mild cases, anxiety symptoms are common.
Psychotic symptoms in the form of auditory hallucinations and somatic
and persecutory delusions may occur in severe depression.
The themes of depressive delusions and hallucinations confirms the
patient’s believe in his guilt and worthlessness (your are evil, it is your
fault), and is accepted by the patient as a punishment for his wrongdoing
(mood congruent).
In schizophrenia, auditory hallucinations and delusions may have the
same themes, but the content is rejected and protested by the patient (it is
not my fault, it is done to me, I do not know why).
The constellation and severity of the symptoms are related to the severity
of depression.
Severe depression presents with more and severe symptoms.
Depressive stupor describes sever physical and mental retardation
characterised by withdrawal from the surroundings, and lack of speech,
response, and movements. Eating and drinking are reduced or stopped.
In masked or smiling depression there are depressive symptoms, but the
mood appears not depressed, and it usually responds to treatment with
antidepressants.
Atypical depression describes depression where the biological symptoms
such as loss of appetite and insomnia are reversed (overeating and
oversleeping); depressed mood is not persistent and responds to change in
circumstances (reactive).
Mood may become irritable rather than depressed especially in young
patients.
The underlying personality in atypical depression is sensitive and reacts
in an exaggerated pattern. This depression responds better to monoamine
oxidase and selective serotonin re-uptake inhibitors than to tricyclic
antidepressants.
In brief recurrent depression the symptoms are severe enough to cause
distress and functional impairment, but the depressive episodes are brief
(2-7 days) and recurrent (about once a month). Mild depressive disorder
(neurotic depression) presents with some depressive symptoms as well as
anxiety, obsessions, phobic, and dissociative symptoms. Sleep
disturbance presents as difficulty in falling asleep, interrupted sleep with
bad dreams, and the mood usually worsens later in the day.
In severe depressive disorder there is early wakening, and the mood
usually improves later in the day (diurnal variation).
Mild depressive symptoms may accompany personal crises (financial
loss, divorce) and resolve after the crises are over (minor depressive
disorders). The person gradually makes adjustments and cope with the
new situation.
However, some individuals are unable to adjust, and although symptoms
are mild, functioning is impaired, may be for years (dysthymia, chronic
depression). Underlying personality factors (constitutional factors) play a
role in these cases. In depression, general appearance (personal care,
grooming, facial expression, posture) and behaviour reflects how the
patient feels.
MANIC DISORDERS: Symptoms of mania are opposite to symptoms
of depression and varies in constellation and severity.
Mood is elated (elevated, euphoria, cheerful, high), but may become
irritable and angry, especial young patients. The patient expects people
around him to share his happiness (infectious mood); otherwise he
becomes crossed and irritable.
The patient feels optimistic, overconfident, and powerful (grandiose) and
behaves accordingly.
He overestimates his capabilities, wealth, and social status and may
spend money recklessly.
Overctivity includes thought process, speech, and mobility. Thoughts
and ideas are optimistic, crowded, and may be contradictory.
Speech is fast and plentiful, and the stream of thoughts may become
disjointed and difficult to follow (flights of ideas).
Appetite is increased and the patient may eat without regard to table
manners. The patient is restless, energetic, and physically active.
Physical activities may become aimless with neglect of personal hygiene
and nutrition and leads to exhaustion.
This imposes stress on colleagues at work and on the family.
Overctivity is often counterproductive and jobs started but remain
unfinished.
Patient may lose insight and becomes uninhibited with to disregard
social standards.
Sexual desire is high and the patient may behave without restraint.
Personal appearance (grooming, cloths, posture) and behaviour reflects
patient’s mood.
Severe cases of mania may show psychotic symptoms in the form of
delusions of reference, grandiose and persecutory delusions, and
hallucinations.
The theme of these psychotic symptoms reflects the elated mood, sense
of power, and self-importance.
Patient may believe he is a profit, a king, or an international personality
(grandiose delusions).
He may believe that because of his high social status there is a conspiracy
against him, (persecutory delusions) and the media print and broadcast
material about him (delusion of reference). Voices talk about the patient’s
special power and importance (you are a profit, you’re a saviour) and
visions may have religious tone (seeing God, surrounded by angels).
Schneider first rank symptoms (thought insertion, withdrawal, and
broadcasting, third person and commentary hallucinations) may occur in
mania.
Similar to depressive disorders, severity and constellation of symptoms
varies with the severity of mania. Less severe cases of mania are
hypomania.
When depressive and manic episodes occur in the same patient,
alternating or merging into each other without remission, the disorder is
called bipolar affective disorder. Recurrent depression without mania is
called unipolar disorder.
Symptoms of depression and mania may be present at the same time
(mixed affective states).
Elated mood may be associated with depressive thoughts or crying.
Mild symptoms of depression may alternate with mild symptoms of
mania i.e hypomania….this called (cyclothymia).
The term manic stupor describes a disorder where the patients is mute or
speak with low voice, lay in bed with no interest in the surroundings, and
looks happy and may smile without apparent cause.
After recovery, the patient recalls events that occurred during the period
of stupor and acknowledges that he had crowded thoughts.
Manic stupor may evolve from manic excitement or from depressive
stupor.
Rapid cycling manic depressive disorder refers to cases in which
episodes of mania, depression, or mixed affective states recur at intervals
of weeks or months (circular insanity, periodic psychosis).
Four episodes a year is required for the diagnosis and episodes may be
separated by remission or merge into each other.
The disorder is more common in females, some of whom have abnormal
thyroid function.
It may be triggered by tricyclic antidepressants and response to lithium is
poor, but it responds better to valproate or carbamazepine.
Seasonal affective disorder refers to depressive or manic episodes that
occur during a particular season in the year
. It is suggested that this disorder be related to the length of daylight.
In seasonal depression there is hypersomnia and increased appetite
(similar to atypical depression) and craving for carbohydrate.
Depression usually occurs in autumn or winter and mania in summer.
Depressive episodes respond to exposure to artificial bright light during
dark hours and sometimes during the day.
Exposure to bright light at night reduces the amount of sleep and it is
known that sleep deprivation temporarily improve depression.
The beneficial effect of light in seasonal affective disorder is more likely
due to light than to sleep deprivation.
Extra light at night suppresses the secretion of melatonin, which may
have some effect.
The terms involutional and senile depression have been discarded
because they are not separate entities.
DSM1V classifies repeated depressive episodes with at least one manic
episode as bipolar-1 affective disorder, and repeated depressive episodes
with hypomania as bipolar-11 affective disorder.
ICD 10 does not use the term bipolar 1 and bipolar 11, only bipolar.
Severe depressive and manic disorders are not difficult to diagnose
because of the severity and constellation of symptoms. Mild depression
may present with additional symptoms of anxiety, phobia, and obsessions
and has to be differentiated from these disorders. History helps to show
which symptoms of these disorders appeared first.
Comorbidity of depression and anxiety disorders is to be considered.
Psychotic symptoms in severe depression and mania may confuse these
disorders with schizophrenia.
The contents and themes of the delusions and hallucinations differentiate
these disorders from each other. In elderly patients, dementia and organic
diseases are to be excluded.
The lifetime risk for bipolar mood disorder ranges between 0.5 to 1.5
percent and is equal for men and women.
The prevalence of mania is probably higher in upper social class and in
artists and intellectuals. Genetics plays a major role in the aetiology of
affective disorders, especially in moderate and severe cases. Morbidity
risk in parents, siblings, and children is 20 percent in sever depression (7
percent in control), and 69 percent in monozygotic twins and 13 percent
in dizygotic twins.
Adoption studies confirmed that morbidity risk in adopted children is
related to that of their biological parents and not to the adopting families.
The role of genetics is higher in bipolar than in unipolar mood disorders.
The mode of genetic transmission is not clearly known.
The role of body build (physique); personality traits; parental
deprivation; and relationship with parents remain ambiguous.
The mean age of onset of bipolar disorders is about 21 years and more
cases occur in teens than in late life.
The natural course of an episode is months and sometimes several years.
Recurrence is a characteristic of bipolar disorders.
In an individual patient, the length of each episode may remain the same,
but periods of remissions become shorter with recurrences.
Men have about equal number of manic and depressive episodes, whereas
women have more depression.
The number of episodes in bipolar disorders is higher than in unipolar
disorders.
Family history of mania increases the risk of recurrence in bipolar
patients.
Unipolar depressive disorders have later age of onset; episodes may last
longer; and are more likely to have chronic residual symptoms.
Recurrence is higher in women and in patients with early age of onset.
In general, unipolar depression has poor outcome.
Mood disorders carries higher risk for suicide than other psychiatric
disorders.
Bipolar and unipolar disorders have similar rate of suicide.
Sever depression is associated with 11 to 17 percent rate of suicide.