MOOD DISORDERS nearly everyday

A: Appetite Significant weight loss when not

Mood dieting or weight gain, or decrease
- Defined as a pervasive and sustained or increase in appetite nearly
emotion or feeling tone that influences a everyday
person’s behavior and colors his or her P: Psychomotor Psychomotor agitation or retardation
perception of being in the world nearly everyday
S: Sleep Insomnia or hyperinsomnia nearly
CLINICAL FEATURES everyday
Depressive episodes B. The symptoms cause clinically significant distress
- Social withdrawal, decreased activity, deny or impairment in social, occupational, or other
depressive feelings important areas of functioning.
- Decreased rate and volume of speech C. The episode is not attributable to the physiological
- Mood congruent delusions and hallucinations effects of a substance or to other medical
- Negative views of the world and themselves conditions.
- Oriented but insufficient energy to answer Note: Criteria A to C represent a major depressive
questions episode.
- Cognitive impairment D. The occurrence of the major depressive episode is
- Depressive thoughts not better explained by schizoaffective disorder,
- Overemphasizing the bad, minimizing the good schizophrenia, schizophreniform disorder, delusional
during conversations disorder, or other specified and unspecified
Manic episodes schizophrenia spectrum and other psychotic disorders.
- Excited, talkative, amusing, frequently E. There has never been a manic episode or a
hyperactive hypomanic episode.
- Euphoric, can also be irritable; low frustration
tolerance BIPOLAR I DISORDER
- Mood congruent delusions DIAGNOSTIC CRITERIA
- Self confidence - Necessary to meet the ff. criteria for a manic
- Accelerated flow of ideas episode
- Assaultive and threatening - May have preceded by and may be followed by
- Little insight about their disorder a hypomanic or major depressive episodes
- Unreliable with information A. A distinct period of abnormally and persistently
elevated, expansive, or irritable mood, increased
DIAGNOSIS goal-directed activity or energy lasting at least 1
Diagnosis is based on DSM-V week and present most of the day, nearly everyday
- Major depressive disorder B. During the period of mood disturbance and increased
- Bipolar I disorder energy or activity, 3 or more of the ff. are present
- Bipolar II disorder D: Distractibility Attention easily drawn to
unimportant or irrelevant external
MAJOR DEPRESSIVE DISORDER stimuli
A. 5 or more of the ff. symptoms have been present I: Indiscretion Excessive involvement in activities
during the same 2 week period and represent a change that have a high potential for painful
from previous functioning: at least 1 of the symptoms is consequences (unrestrained buying
either: (a) depressed mood or (b) loss of interest or sprees, sexual indiscretions, or
pleasure foolish business investments)
S: Suicide Recurrent thoughts of death (not G: Grandiosity Inflated self-esteem or grandiosity
just fear of dying), recurrent suicidal F: Flight of ideas Flight of ideas or subjective
ideation without a specific plan, or a experience that thoughts are racing
suicide attempt, or a specific plan A: Activity Increase in goal-directed activity
for committing suicide (either socially, at work/school,
I: Interest Markedly diminished interest or sexually) or psychomotor agitation
pleasure in all, or almost all (i.e. purposeless non-goal-directed
activities most of the day, nearly activity)
everyday S: Sleep Decreased need for sleep (e.g. feels
G: Guilt Feelings of worthlessness or rested after only 3 hours of sleep)
excessive or inappropriate guilt T: Talks fast More talkative than usual or
nearly everyday pressure to keep talking
E: Energy Fatigue or loss of energy nearly MANIC EPISODE
everyday C. The mood disturbance is sufficiently severe to
C: Concentration Diminished ability to think or necessitate hospitalization to prevent harm to self or
concentrate, or indecisiveness, to others, or there are psychotic symptoms
D. The episode is not attributable to the physiological
effects of a substance (e.g. a drug of abuse, a
medication, other treatment) or to another medical
condition
HYPOMANIC EPISODE
C. The episode is associated with unequivocal change
in functioning that is uncharacteristic of the individual
when not symptomatic
D. The disturbance in mood and change in functioning
are observable by others
E. The episode is not severe enough to cause marked
impairment in social or occupational functioning
F. The episode is not attributable to the physiological
effects of a substance (e.g. a drug of abuse, a
medication, other treatment) or to another medical
condition
Hypomanic episodes are common in Bipolar I, but are
not required for the diagnosis of Bipolar II.
MAJOR DEPRESSIVE EPISODE
A. 5 or more of the ff. symptoms present during the
same 2 week period and represent a change from
previous functioning; at least 1 of the symptoms is
either: (a) depressed mood or (b) loss of interest or
pleasure
S: Suicide
I: Interest
G: Guilt
E: Energy
See descriptions above
C: Concentration
A: Appetite
P: Psychomotor
S: Sleep
BIPOLAR II DISORDER
DIAGNOSTIC CRITERIA
- At least 1 hypomanic episode (current or past)
+ at least 1 major depressive episode (current
or past)
- There has never been a manic episode
- The occurrence of the hypomanic episode/s and
major depressive episode/s is not better
explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder,
delusional disorder, or other specified or
unspecified schizophrenia spectrum and other
psychotic disorder
- The symptoms of depression or the
unpredictability caused by frequent alteration
between periods of depression and hypomania
causes clinically significant distress or
impairment in social, occupational, or other
important areas of functioning
ETIOLOGY
BIOLOGICAL FACTORS
A. Biogenic amines
- Norepinephrine, serotonin, dopamine
B. Other neurotransmitter disturbances
- Acetylcholine, GABA, glutamate, glycine
C. Second messengers and intracellular
cascades
D. Alterations of hormonal regulations
- Elevated HPA axis, thyroid axis activity, growth
hormone, prolactin
E. Alterations in sleep neurophysiology
F. Immunological disturbance
G. Neuroanatomical considerations
- Prefrontal cortex, anterior cingulate cortex,
hippocampus, amygdala
GENETIC FACTORS
A. Family studies
B. Adoption studies
C. Twin studies
D. Linkage studies
- Chromosomes 18q and 22q are the regions with
the strongest evidence for linkage to bipolar
disorder
PSYCHOSOCIAL FACTORS
A. Life events and environmental stress
B. Personality factors
- No single personality trait or type uniquely
predisposes a person to depression; certain
personality disorders such as OCD, histrionic,
and borderline may be at greater risk for
depression than persons with antisocial or
paranoid personality disorder
OTHER FORMULATIONS OF DEPRESSION
A. Cognitive theory
B. Learned helplessness
MANAGEMENT
COGNITIVE BEHAVIORAL THERAPY
- Combines established cognitive and behavioral
theories into one method that focuses on the
actions and behaviors. Learning to recognize
distorted or self-defeating though patterns,
and then actively working to replace them
with healthier beliefs
- Patient should uncover unhealthy, negative
beliefs and patterns such as black-and-white
thinking patterns, generalizing all situations with
a negative bias, overlooking the positive side of
situations, assuming the worst is about to
happen, etc.
ELECTROCONVULSIVE THERAPY (ECT)
- Uses electrical stimulation of the brain to help
patients who experience major depression or
suicidal thoughts; modern protocols are safer
and more effective than those used in the past
NATURAL SUPPLEMENTS
- St. John’s wort, omega-3 fatty acids, and –
adenosylmethionine
- Shown to improve mood, stabilize emotions, and
lessen anxiety
- Generally thought to be safe to use and free of
major side effects
ALTERNATIVE HEALTH PRACTICES
- Meditation, deep breathing exercises, acupuncture,
yoga, qi-gong
TREATMENT FOR MAJOR DEPRESSION
I. TRICYCLIC ANTIDEPRESSANTS Generic/Brand Usual daily
Common A/E
Generic/Brand Usual daily name dose (mg)
Common A/E
name dose (mg) Mirtazapine Sedation, weight
15
Imipramine (Remeron) gain
75
(Tofranil) VII. DOPAMINE REUPTAKE INHIBITOR
Trimipramine Generic/Brand Usual daily
75 Common A/E
(Surmontil) name dose (mg)
Amitriptyline Insomnia,
75 Buproprion
(Elavil, Endep) 200 agitation, GI
(Wellbutrin)
Doxepin Drowsiness, distress
75
(Triadapin) OSH, CA, weight VIII. SEROTONIN 2A ANTAGONIST REUPTAKE INH.
Desipramine gain, Generic/Brand Usual daily
75 Common A/E
(Norpramin) anticholinergic name dose (mg)
Protriptyline Drowsiness,
20
(Vivactil) Trazodone OSH, CA, GI
150
Nortriptyline (Desyrel) upset, weight
40
(Aventyl) gain
Maprotiline
100
(Ludiomil) TREATMENT FOR BIPOLAR DISORDERS
Clomipramine Drowsiness, Agent Mania Maintenance
75
(Anafanil) weight gain Aripiprazole YES NO
II. MONOAMINE OXIDASE INHIBITORS Carbamazepine YES NO
Generic/Brand Usual daily Divalproex YES NO
Common A/E
name dose (mg) Lamotrigine NO YES
Tranylcypromine 30 Olanzapine YES NO
Isocarboxazid 20 HPN crisis Risperidone YES NO
Phenelzine 30 Ziprasidone YES NO
Moclobemide 300 Less HPN effect Quetiapine YES NO
Dizziness, Lithium YES YES
abdominal pain,
Selegiline 1.25 dry mouth, ANXIETY
nausea, GI
upset Anxiety
III. SELECTIVE NORADRENERGIC REUPTAKE INH. - An emotion characterized by feelings of
Generic/Brand Usual daily tension, worried thoughts, and physical
Common A/E
name dose (mg) changes like increased BP
Pseudo- - People with anxiety disorders usually have
Reboxitine 8 anticholinergic recurring intrusive thoughts or concerns,
effect they may avoid certain situations out of worry
IV. SEROTONIN REUPTAKE INHIBITORS
Generic/Brand Usual daily CLINICAL FEATURES
Common A/E
name dose (mg) - Diffuse, unpleasant, vague sense of
Sertraline apprehension
50
(Zoloft) - Autonomic symptoms such as diarrhea,
All SSRIs may
Escitalopram dizziness, headache, chest tightness, etc.
10 cause insomnia,
(Lexapro) - Inability to stand/seat for too long
agitation,
Citalopram
20 sedation, GI
(Celexa) ETIOLOGY
upset, and
Fluxetine PSYCHOANALYTIC THEORY
10 sexual
(Prozac) - Conflict between id and superego
dysfunction
Fluvoxamine LEARNING THEORIES
100
(Luvox) - Anxiety is a conditioned response to an
V. SEROTONIN NOREPINEPHRINE REUPTAKE INH. environmental stimulus
Generic/Brand Usual daily EXISTENTIAL THEORIES
Common A/E
name dose (mg) - Anxiety is a response to the purposeless universe
Sleep changes, BIOLOGICAL SCIENCE
GI upset, - ANS stimulation gives rise to systemic
Venlafaxine
150 discontinuation symptoms such as tachycardia, diarrhea,
(Effexor)
syndrome headache, etc.
- Neurotransmitters (NE, GABA, serotonin)
VI. ALPHA 2 ANTAGONIST - HPA axis stress-induced release of cortisol
BRAIN STUDIES
- Increased size of ventricles
- Abnormal right hemisphere, but not the left
- Abnormalities on frontal cortex, occipital,
temporal, and parahippocampal areas
- Increased activity of amygdala
GENETIC STUDIES
- Heredity and genetics are recognized as
predisposing factors
NEUROANATOMICAL CONSIDERATIONS
- Limbic system receives noradrenergic and
serotonergic innervation; also contains high
levels of GABA receptors; participate in the
generation of fear and anxiety
- Cerebral cortex with its connection to the
parahippocampal, cingulate gyrus, and
hypothalamus – involved in generating anxiety