Mood Disorders

Mood disorders involve severe alterations of mood for much longer period of time. The
disturbances of mood are intense and persistent enough to be clearly maladaptive and often lead
to serious problems in relationships and work performance.

In all mood disorders (formerly called affective disorders), extremes of emotion or affect—
soaring elation or deep depression—dominate the clinical picture. Other symptoms are also
present, but the abnormal mood is the defining feature.

Broadly speaking, the emotions can be described as two main types:

1. Affect, which is a short-lived emotional response to an idea or an event, and
2. Mood, which is a sustained and pervasive emotional response which colors the whole psychic
life.

Mood can be defined as a pervasive and sustained emotion or feeling tone that influences a
person’s behavior and colors his or her perception of being in the world. Disorders of mood —
sometimes called affective disorders—make up an important category of psychiatric illness
consisting of depressive disorder, bipolar disorder, and other disorders. A variety of adjectives
are used to describe mood: depressed, sad, empty, melancholic, distressed, irritable, disconsolate,
elated, euphoric, manic, gleeful, and many others, all descriptive in nature. Some can be
observed by the clinician (e.g., an unhappy visage), and others can be felt only by the patient
(e.g., hopelessness). Mood can be labile, fluctuating or alternating rapidly between extremes
(e.g., laughing loudly and expansively one moment, tearful and despairing the next). Other signs
and symptoms of mood disorders include changes in activity level, cognitive abilities, speech,
and vegetative functions (e.g., sleep, appetite, sexual activity, and other biological rhythms).
These disorders virtually always result in impaired interpersonal, social, and occupational
functioning.

Patients with only major depressive episodes are said to have major depressive disorder or
unipolar depression. Patients with both manic and depressive episodes or patients with manic
episodes alone are said to have bipolar disorder. The terms “unipolar mania” and “pure mania”
are sometimes used for patients who are bipolar but who do not have depressive episodes.

Three additional categories of mood disorders are hypomania, cyclothymia, and dysthymia.
Hypomania is an episode of manic symptoms that does not meet the criteria for manic episode.
Cyclothymia and dysthymia as disorders that represent less severe forms of bipolar disorder and
major depression, respectively.

The field of psychiatry has considered major depression and bipolar disorder to be two separate
disorders, particularly in the past 20 years. The possibility that bipolar disorder is actually a more
severe expression of major depression has been reconsidered recently, however. Many patients
given a diagnosis of a major depressive disorder reveal, on careful examination, past episodes of
manic or hypomanic behavior that have gone undetected. Many authorities see considerable
continuity between recurrent depressive and bipolar disorders. This has led to widespread
discussion and debate about the bipolar spectrum, which incorporates classic bipolar disorder,
bipolar II, and recurrent depressions.
DSM vs ICD

DSM ICD
Two separate
categories for A single category -
unipolar and bipolar mood disorders
disorders

Disorders due to Other mental

other medical disorders due to
conditions listed known ohysiological
under the same condition listed under
category a separate category

Premenstrual Menstruation and

dysphoric disorder is related issues are
listed under under a different
depression category

Mood Episodes
 The symptoms of depression includes markedly depressed mood or lose of interest in
formerly pleasurable activities. It also included change in apppetite and/or sleep and feeling
of worthlesseness

Symptoms of mania inclueds markedly elevated, euphoric, or expansive mood, often

interrupted by occasional outbursts of intense irritability or even violence—particularly when
others refuse to go along with the manic person’s wishes and schemes. Other symptoms
inclued behavioral symptoms (such as a notable increase in goal-directed activity, to mental
symptoms where self-esteem becomes grossly inflated and mental activity may speed up
(such as a “flight of ideas” or “racing thoughts”), to physical symptoms (such as a decreased
need for sleep or psychomotor agitation).

A person experiences abnormally elevated, expansive, or irritable mood for at least 4 days. In
addition, the person must have at least three other symptoms similar to those involved in
mania but to a lesser degree (e.g., inflated self-esteem, decreased need for sleep, flights of
ideas, pressured speech, etc.). Although the symptoms listed are the same for manic and
hypomanic episodes, there is much less impairment in social and occupational functioning in
hypomania, and hospitalization is not required.

Clinical Picture of Manic Episode

A manic episode is typically characterized by the following features (which should last for at
least one week and cause disruption in occupational and social Activities)

Elevated, Expansive or Irritable Mood

The elevated mood can pass through following four stages, depending on the severity of manic
episode:
a. Euphoria (mild elevation of mood): An increased sense of psychological well-being and
happiness, not in keeping with ongoing events. This is usually seen in hypomania (Stage I).
b. Elation (moderate elevation of mood): A feeling of confidence and enjoyment, along with an
increased psychomotor activity. Elation is classically seen in mania (Stage II).
c. Exaltation (severe elevation of mood): Intense elation with delusions of grandeur; seen in
severe mania (Stage III).
d. Ecstasy (very severe elevation of mood): Intense sense of rapture or blissfulness; typically
seen in delirious or stuporous mania (Stage IV).
Along with these variations in elevation of mood, expansive mood may also be present, which is
an unceasing and unselective enthusiasm for interacting with people and surrounding
environment. At times, elevated mood may not be apparent and instead an irritable mood may be
predominant, especially when the person is stopped from doing what he wants. There may be
rapid, short lasting shifts from euphoria to depression or irritability.

Psychomotor Activity
There is an increased psychomotor activity, ranging from over activeness and restlessness, to
manic excitement where the person is ‘on-the-toe-on-the-go’, (i.e. involved in ceaseless activity).
The activity is usually goal-oriented and is based on external environmental cues. Rarely, a
manic patient can go in to a stuporous state (manic stupor).

Speech and Thought

The person is more talkative than usual; describes thoughts racing in his mind; develops pressure
of speech; uses playful language with punning, rhyming, joking and teasing; and speaks loudly.
Later, there is ‘flight of ideas’ (rapidly produced speech with abrupt shifts from topic to topic,
using external environmental cues. Typically the connections between the shifts are apparent).
When the ‘flight’ becomes severe, incoherence may occur. A less severe and a more ordered
‘flight’, in the absence of pressure of speech, is called ‘prolixity’. There can be delusions (or
ideas) of grandeur (grandiosity), with markedly inflated self-esteem. Delusions of persecution
may sometimes develop secondary to the delusions of grandeur (e.g. I am so great that people are
against me). Hallucinations (both auditory and visual), often with religious content, can occur
(e.g. God appeared before me and spoke to me). Since these psychotic symptoms are in keeping
with the elevated mood state, these are called mood congruent psychotic features. Distractibility
is a common feature and results in rapid changes in speech and activity, in response to even
irrelevant external stimuli.

Goal-directed Activity
The person is unusually alert, trying to do many things at one time. In hypomania, the ability to
function becomes much better and there is a marked increase in productivity and creativity.
Many artists and writers have contributed significantly in such periods. As past history of
hypomania and mild forms of mania is often difficult to elicit, it is really important to take
additional historical information from reliable informants (e.g. family members).
In mania, there is marked increase in activity with excessive planning and, at times, execution of
multiple activities. Due to being involved in so many activities and distractibility, there is often a
decrease in the functioning ability in later stages. There is marked increase in sociability even
with previously unknown people. Gradually this sociability leads to an interfering behaviour
though the person does not recognize it as abnormal at that time. The person becomes impulsive
and disinhibited, with sexual indiscretions, and can later become hypersexual and promiscuous.

Due to grandiose ideation, increased sociability, over activity and poor judgement, the manic
person is often involved in the high-risk activities such as buying sprees, reckless driving, foolish
business investments, and distributing money and/or personal articles to unknown persons. He is
usually dressed up in gaudy and flamboyant clothes, although in severe mania there may be poor
self-care.

Other Features
Sleep is usually reduced with a decreased need for sleep. Appetite may be increased but later
there is usually decreased food intake, due to marked over activity. Insight into the illness is
absent, especially in severe mania. Psychotic features such as delusions, hallucinations which are
not understandable in the context of mood disorder (called mood incongruent psychotic
features), e.g. delusions of control, may be present in some cases.

Clinical Picture of Depressive Episode

The typical depressive episode is characterized by the following features

Depressed Mood
The most important feature is the sadness of mood or loss of interest and/or pleasure in almost all
activities (pervasive sadness), present throughout the day (persistent sadness). This sadness of
mood is quantitatively as well as qualitatively different from the sadness encountered in ‘normal’
sadness or grief.
The depressed mood varies little from day to day and is often not responsive to the
environmental stimuli.
The loss of interest in daily activities results in social withdrawal, decreased ability to function in
occupational and interpersonal areas and decreased involvement in previously pleasurable
activities. In severe depression, there may be complete anhedonia (inability to experience
pleasure).

Depressive Ideation/Cognition
Sadness of mood is usually associated with pessimism, which can result in three common types
of depressive ideas. These are:
a. Hopelessness (there is no hope in the future).
b. Helplessness (no help is possible now).
c. Worthlessness (feeling of inadequacy and inferiority).
The ideas of worthlessness can lead to self-reproach and guilt-feelings. The other features are
difficulty in thinking, difficulty in concentration, indecisiveness, slowed thinking, subjective
poor memory, lack of initiative and energy. Often there are ruminations (repetitive, intrusive
thoughts) with pessimistic ideas. Thoughts of death and preoccupation with death are not
uncommon. Suicidal ideas may be present. In severe cases, delusions of nihilism (e.g. ‘world is
coming to an end’, ‘my brain is completely dead’, ‘my intestines have rotted away’) may occur.

Psychomotor Activity
In younger patients (< 40 year old), retardation is more common and is characterized by slowed
thinking and activity, decreased energy and monotonous voice. In a severe form, the patient can
become stuporous (depressive stupor). In the older patients (e.g. post-menopausal women),
agitation is commoner. It often presents with marked anxiety, restlessness (inability to sit still,
hand wriggling, picking at body parts or other objects) and a subjective feeling of unease.
Anxiety is a frequent accompaniment of depression. Irritability may present as easy annoyance
and frustration in day-to-day activities, e.g. unusual anger at the noise made by children in the
house.

Physical Symptoms
Multiple physical symptoms (such as heaviness of head, vague body aches) are particularly
common in the elderly depressives and depressed patients from the developing countries (such as
India). However, the recent literature has shown that multiple physical symptoms (called general
aches and pains) are present in most patients even in the
Western world and they can be elicited only if physicians routinely ask the patients for their
presence.
Hypochondriacal features may be present in up to a quarter of depressives presenting for
treatment. These physical symptoms are almost always present in severe depressive episode.
Another common symptom is the complaints of reduced energy and easy fatigability. The
patients, therefore, not surprisingly attribute their symptoms to physical cause(s) and consult a
physician instead of a psychiatrist.

Biological Functions
Disturbance of biological functions is common, with insomnia (or sometimes increased sleep),
loss of appetite and weight (or sometimes hyperphagia and weight gain), and loss of sexual
drive. When the disturbance is severe, it is called as melancholia (somatic syndrome in ICD-10-
DCR; Diagnostic Criteria for Research). The somatic syndrome of depression is described in
Table 6.1. The presence of somatic syndrome in depressive disorder signifies higher severity and
more biological nature of the disturbance. It often also implies a good response to somatic
methods of treatment (e.g. pharmacotherapy, ECT).

Psychotic Features
About 15-20% of depressed patients have psychotic symptoms such as delusions, hallucinations,
grossly inappropriate behaviour or stupor. The psychotic features can be either mood-congruent
(e.g. nihilistic delusions, delusions of guilt, delusions of poverty, stupor) which are
understandable in the light of depressed mood, or can be mood-incongruent (e.g. delusions of
control) which are not directly related to depressive mood.

Suicide
Suicidal ideas in depression should always be taken very seriously. Although there is a risk of
suicide in every depressed patient with suicidal ideation, presence of certain factors increases the
risk of suicide.

Absence of Underlying Organic Cause

If depressive episode is secondary to an organic cause, a diagnosis of organic mood disorder
should be made. In ICD-10, the severity of depressive episode is defined as mild, moderate or
severe, depending primarily on the number of the symptoms, but also on the severity of
symptoms and the degree of impairment.